Comprehensive Care for Joint Replacement (CJR)

Appeals Process

Appeals Process

Examples of Appeals

• CJR hospitals may appeal errors in payment or reconciliation. Examples include:• Calculation of reconciliation payments or

repayments• Calculation of the NPRA• Calculation of percentile of quality measure

performance• Determination of successful reporting of

voluntary PRO THA/TKA data

What CJR Hospitals Cannot Appeal

• CJR hospitals may not appeal:• Selection of the CJR model for testing by

CMS• Selection of a hospital to participate in the

CJR model• Details of the CJR model implementation• Termination of or design modifications of

the CJR model, including expansions of its duration or scope

First Level of Appeal Process

• CMS has established an appeal process similar to that used in other programs.

• The first level of appeal of a potential error requires the participant hospital to notify CMS of the error within 45 days (utilizing a calculation error form) or the relevant calculation will be deemed final.

First Level of Appeals Process (continued)

• CMS will respond in writing within 30 days and either agree or disagree or provide notice of an extension.

• Only the participant hospital can use this process.

Second Level of Appeals Process

• The second level of appeal is a dispute resolution process. This involves a request for reconsideration of an adverse determination to the first level of appeal.

• The request must include a detailed explanation of the basis for the dispute and include supporting documentation and is due within ten days of CMS’s response to the participant hospital’s notice of calculation error.

CMS Review and Decision

• CMS will notify the participant hospital of receipt and next steps and the review by CMS will occur within 30 days of that notice.

• A written determination will be issued by CMS within 30 days and will be final and binding.

To download the full CJR report, click on the image below