Follow the steps to successfully fill out the HHS OMHA form online.

1. Press the ‘Get Form’ button to access the HHS OMHA Request For Settlement Conference Facilitation form and open it in your preferred digital editing tool.
2. In the first field, enter the name of the appellant, which refers to the provider or supplier that is appealing the reconsideration decision.
3. Provide the appellant point of contact information. This information is not necessary if the appellant is represented by an attorney.
4. If applicable, fill in the representative or attorney's name and their associated title.
5. Complete the representative firm or business name field, if relevant.
6. Input the email address of the point of contact to ensure communication on the appeal.
7. Enter the street address, city, state, and ZIP code for the appellant or representative.
8. Include the phone number, and fax number if necessary.
9. Fill in the National Provider Identifier (NPI) and corresponding Provider Transaction Access Number (PTAN) or CMS Certification Number (CCN). Ensure these numbers are typed and not handwritten, as OMHA does not accept handwritten submissions.
10. Indicate whether the claims are pre-payment and/or post-payment denials by checking the appropriate boxes.
11. Confirm whether all claims are covered under Medicare Part A and/or Medicare Part B by checking the respective boxes.
12. Answer the questions regarding the timeliness of requests for ALJ hearings, the amount in controversy, and whether the appeals are awaiting scheduling for a hearing.
13. Respond to other eligibility questions regarding litigation, bankruptcy, and claims involving unlisted healthcare codes.
14. Acknowledge and understand the responsibilities and conditions for the SCF process by reading the stipulations provided before signing.
15. Sign the form, print your name, and date it to finalize the request.
16. Once all sections are completed, save your document as a PDF. You can then email your completed Request for Settlement Conference Facilitation to OMHA_SCFAppeals@cms.hhs.gov.

Begin the process of filling out your HHS OMHA Request For Settlement Conference Facilitation form online today.