Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to access the HHS OMHA Request For Settlement Conference Facilitation document and open it for editing.
2. In the first field, enter the name of the appellant, who is the provider or supplier that appealed the reconsideration.
3. If you have a point of contact, provide their name and title. You may leave this blank if you are not represented.
4. Fill in the representative or attorney's name, if applicable, as well as the associated firm or business.
5. Provide valid email addresses for contact and ensure accuracy to facilitate correspondence.
6. Complete the street address, city, state, and ZIP code for both the appellant and the representative if applicable.
7. Enter the phone number, including an extension if necessary, and provide a fax number if you have one.
8. Input the National Provider Identifier (NPI) and corresponding Provider Transaction Access Number (PTAN) or CMS Certification Number (CCN). Ensure you do not handwrite these numbers.
9. Indicate whether the claims are pre-payment and/or post-payment denials by checking the appropriate boxes.
10. Confirm if all claims are covered under Medicare Part A and/or Part B by checking the appropriate boxes.
11. Answer the questions regarding the timeliness of requests for ALJ hearings or Council reviews.
12. Verify if the amount in controversy criteria is met for all appeals as specified.
13. Indicate whether there are any pending or expected bankruptcy filings.
14. At the end of the form, read and understand the eligibility terms for the SCF process and affirm your understanding.
15. Once all fields are completed, you can save the document as a PDF and email it to the specified address, ensuring you attach any additional required documentation.

Ready to initiate your request? Complete the form online today.