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FORM OMHA Request For Settlement Conference Facilitation. Request for Settlement Conference Facilitation 2026
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How to use or fill out FORM OMHA Request For Settlement Conference Facilitation
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- Click ‘Get Form’ to open it in the editor.
- 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.
- 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.
- 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.
- Indicate whether claims are pre-payment and/or post-payment denials by checking the appropriate boxes.
- 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.
- 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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