FORM OMHA Request For Settlement Conference Facilitation. Request for Settlement Conference Facilitation 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the appellant's name in the designated box. This is crucial as it identifies the provider or supplier appealing the QIC reconsideration.
3. Fill out the contact information, including email address, street address, and phone number. If you have a representative or attorney, include their details as well.
4. Provide your National Provider Identifier (NPI) and corresponding Provider Transaction Access Number (PTAN) or CMS Certification Number (CCN). Ensure these numbers are typed, as handwritten entries will not be accepted.
5. Indicate whether claims are pre-payment and/or post-payment denials by checking the appropriate boxes.
6. Answer questions regarding Medicare Part A and B coverage, timely filing of requests for ALJ hearing, and eligibility criteria for SCF. Mark 'Yes' or 'No' accordingly.
7. Review all entered information for accuracy before signing. Once completed, save your document as a PDF and submit it via email to OMHA_SCFAppeals@cms.hhs.gov.

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