DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
SETTLEMENT CONFERENCE FACILITATION
AGREEMENT OF PARTICIPATION
Note: This is an accessible version of this form, to be completed only by individuals with a disability that would prevent the individual from
entering a handwritten signature. All other individuals should use the version of the Settlement Conference Facilitation Agreement of
Participation that requires a handwritten signature, available on the OMHA website at
www.hhs.gov/omha
.
Please submit this agreement, along with your completed SCF Request Spreadsheet, to
E-mail submission of all materials is mandatory. Please attach your signed Agreement of Participation in PDF format.
Settlement Conference Terms
Instructions: Appellants please complete the section below.
I understand and agree to the following:
OMHA_SCFAppeals@cms.hhs.gov
.
•
An individual authorized to sign a binding agreement on behalf of the appellant(s) must be present at the settlement conference
session and the request for Settlement Conference Facilitation will be closed if an authorized individual does not appear at the
conference;
•
The appellant has not filed for bankruptcy and/or is not expected to file for bankruptcy in the future;
•
I understand that the settlement agreement may be void if the appellant has filed for bankruptcy or is expected to file for
bankruptcy in the near future;
•
Regardless of whether a settlement agreement is reached, I will not seek fees under the Equal Access to Justice Act (EAJA);
•
I understand the Centers for Medicare and Medicaid Services (CMS) will not pay fees under EAJA;
•
I agree to limit discussion of the appeals in my Settlement Conference Facilitation Spreadsheet to the Settlement Conference
Facilitation process. I verify that the appeals on the spreadsheet meet the Settlement Conference eligibility requirements;
•
I agree that I will not separately contact any individual within any division of CMS or its contractors regarding such
appeals throughout the duration of the Settlement Conference Facilitation process;
•
I understand that the U.S. Department of Justice must approve any proposed settlement agreements that involve appealed
claims with billed charges in excess of $100,000 or an appeal(s) of an extrapolated overpayment in excess of $100,000;
•
If a settlement agreement is reached, it will be binding and not appealable;
•
If a settlement agreement is reached, by signing the agreement, I will be agreeing to withdraw all of the requests for an ALJ
hearing and/or requests for Medicare Appeals Council review and not pursue further appeals for the items or services covered by
the settlement agreement;
•
If a settlement is reached, the settlement does not exempt the appeals from review for potential fraud and any civil or criminal
actions that commence as a result of such a review; and
•
I understand that these terms apply to all of the providers/suppliers listed in the Provider/Supplier Identification section of this
Agreement of Participation.
Appellant Signature Appellant Printed Name Date
OMHA (06/19)
PAGE 1 OF 4
PSC Publishing Services (301) 443-6740.
EF
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