Fillable Ryan-Re-Review-Form Request for Re-Review of Medicare Claims Related to the Settlement Agreement in Ryan V. Price, 08.2018

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Ryan-Re-Review-Form Request for Re-Review of Medicare Claims Related to the Settlement Agreement in Ryan V. Price, 08.2018

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
REQUEST FOR RE-REVIEW OF MEDICARE CLAIMS RELATED TO
THE SETTLEMENT AGREEMENT IN RYAN V. PRICE
BACKGROUND
On January 11, 2018, the U.S. District Court for the District of Vermont approved a settlement agreement in the
case of Ryan v. Price (Ryan). As part of the Ryan settlement agreement, Medicare will re-review eligible claims
for Home Health services that were denied on the basis that the beneficiary class member was not “confined
to home,” otherwise referred to as not meeting Medicare “homebound” requirements, when that beneficiary
had previously received a determination through the Medicare appeals process that the beneficiary had met the
homebound requirements.
RE-REVIEW OF DENIED CLAIMS
The Ryan settlement agreement provides for the re-review of certain denied Medicare claims in order to apply
the “great weight” review criteria as previously found in § 6.2.1 (B) of the Medicare Program Integrity Manual to
determine whether the beneficiary meets the homebound requirement under the Medicare home health benefit.
This re-review process is available only to beneficiaries in Connecticut, Maine, Massachusetts, New Hampshire,
New York, Rhode Island, or Vermont.
DOES YOUR CLAIM QUALIFY FOR RE-REVIEW UNDER THE RYAN SETTLEMENT AGREEMENT?
In order to qualify for re-review under the Ryan settlement agreement, your claim must meet certain criteria.
Please answer the following questions about your claim to determine whether it qualifies to be re-reviewed.
1. Are you a Medicare beneficiary (or an appointed or authorized representative of
a beneficiary) in Connecticut, Maine, Massachusetts, New Hampshire, New York,
Rhode Island, or Vermont?
Note: Providers, suppliers, Medicaid state agencies, or other insurers may not request
re-review on behalf of a beneficiary under the terms of the settlement agreement.
YES NO
DON’T
KNOW
2. Did you receive home health services on or before August 2, 2015 that Medicare
denied on or after January 1, 2010 on the basis of not being homebound or
confined to home?
YES
NO
DON’T
KNOW
3. Prior to the Medicare denial referenced in question #2 above, had you
received a favorable final decision in the Medicare appeals process that you were
homebound or confined to home?
Note: The favorable final appellate decision could come from any of the four levels
of Medicare administrative appeal.
YES NO
DON’T
KNOW
4. Did you appeal the Medicare denial referenced in question #2 above and was that
appeal pending or within the time for appeal at any level of Medicare administrative
appeal as of March 5, 2015?
YES
NO
DON’T
KNOW
5. Were the services referenced
in question #2 above not covered or paid for by
Medicare or by any insurer?
Note: Insurer does not include Medicaid.
YES NO
DON’T
KNOW
(08/2018) 1
If you answered “YES” or “DON’T KNOW” to all of the questions above, you may be eligible to receive re-review
of the Medicare denial referenced in question #2 above under the Ryan settlement agreement. To request
re-review, please complete the re-review request form below, submit the requested documentation, and certify
that the information included on the form is accurate to the best of your knowledge. If a telephone number is
provided, you may be contacted further for additional information. If you want further information or assistance,
consult the website of Vermont Legal Aid at https://vtlawhelp.org/ for information about the right to re-review
under the Ryan settlement agreement.
TIMEFRAME FOR REQUESTING A RE-REVIEW
YOUR REQUEST FOR RE-REVIEW MUST BE POSTMARKED/FAXED NO LATER THAN:
AUGUST 1, 2019
SUBMIT FORM AND REQUESTED DOCUMENTATION TO ONE OF THE FOLLOWING:
FAX
Subject Line: RYAN
Review
Fax Number: (315) 442-4391
MAIL
National Government Services, Inc.
Appeals Department — Ryan Review
P.O. Box 7111
Indianapolis, IN 46207–7111
(08/2018) 2
in Question #2
REQUEST FOR RE-REVIEW OF MEDICARE CLAIMS RELATED TO THE SETTLEMENT AGREEMENT
Beneficiary’s Name (First Name, Last Name) Health Insurance Claim Number
Requester’s Name (If Different from Beneficiary) Relationship to Beneficiary
Address of Person Requesting Re-Review of Claim Telephone # of Person Requesting Re-Review of Claim
Date(s) of Service of Home Health Service(s) Referenced Date(s) of Initial Denial by Medicare of the Claims for Payment
for Home Health Service(s) Referenced in Question #2
Appeal or Correspondence Number for Appeal(s) of Denial
of Home Health Claim Referenced (See Question #4)
**Include copy of decision(s) if available
Date of Appeal(s) of Denial of Home Health Claim
(See Question #4)
Name of Person/Entity That Filed Appeal of Denial of
Home Health Claim (See Question #4)
Relationship to Beneficiary
Appeal or Correspondence Number of Prior Favorable
Final Appellate Decision That Beneficiary Was
Homebound (See question #3)
**Include copy of decision if available
Date of Prior Favorable Final Appellate Decision That
Beneficiary Was Homebound (See question #3)
REASON(S) FOR DISAGREEMENT WITH THE FINAL CLAIM DECISION
Do you have additional evidence that you would like Medicare to consider?
(If yes, attach to form.)
YES NO
SIGNATURE OF PERSON REQUESTING RE-REVIEW OF CLAIM
I hereby certify that the foregoing information is true, accurate, and complete to the best of my knowledge.
(Please sign and date in the spaces below and submit this page with your request for review.)
To help process your claim, please also include with your request page 1 of this form showing answers to
Questions 1-5.
PRIVACY STATEMENT
The legal authority for the collection of information on this form is authorized by section 1869 (a)(3) of the Social
Security Act.
The information provided will be used to further document your appeal. Submission of the information requested on this
form
is voluntary, but failure to provide all or any part of the requested information may affect the determination of your
request. Information
you furnish on this form may be disclosed by the Centers for Medicare & Medicaid Services to another
person or government agency only with
respect to the Medicare Program and to comply with Federal laws.
(08/2018) 3
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Ryan-Re-Review-Form Request for Re-Review of Medicare Claims Related to the Settlement Agreement in Ryan V. Price, 08.2018

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Completed 18 September 2019

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