Home Care Rate Appeal Form
Home Care Rate Appeal Form
NYS Department of Health - Office of Health Insurance Programs - Division of Finance and Rate Setting
In accordance with Section 505.14(h)(7)(iii)(c) of NYCRR 18, providers have 90 Days from the date of the rate notification Dear Administrator Letter (DAL), to submit a request for a Rate Appeal and revision of the posted rates. Please e-mail the filled out and signed Form to: CHHA-rates@health.ny.gov – for Certified Home Health Agencies (CHHA), or PersonalCare-Rates@health.ny.gov – for Personal Care / Consumer Directed Personal Assistance Program Agencies.
Agency Contact Information (must be an Agency CEO or CFO):
| 1. Agency Name: |
2. Medicaid MMIS ID ID # |
3. Federal Tax ID: |
||
| 4a. Street Address: |
4b. City: |
4c. State: |
4d. ZIP Code: |
|
| 5a. Contact Name: |
5b. Contact Title: |
6. Telephone # |
7. Email Address: |
|
Appeal Details:
| Reason for Appeal In accordance with per Section 505.14(h)(7)(iii)(c) of NYCRR 18, Department will only consider the appeal requests that adhere to the below criteria: |
Rate Setting Schedules (3, 4, 5 and 7) That Apply and Require Adjustments According to Section 505.14(h)(7)(iii)(c) | Documentation Required for DOH Review |
|---|---|---|
| Mathematical, statistical, fiscal, or clerical errors exist, including data submission errors in cost reports. | Adjusted cost report submission via the web-based Tool and required supporting documentation submitted via the SFTP site |
|
| New or unanticipated costs associated with programs or services mandated or approved by the Commissioner. | ||
| New or unanticipated costs associated with programs or services mandated or approved by the Commissioner. |
Description of Basis for Rate Appeal and Adjustments Requested: (attach additional pages if necessary)
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Supporting Documentation Included:
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Agency Certifier's (CFO or CEO) Signature: ______________________________________________________________ Date: ____________________
Certifier's Name and Title: ____________________________________________________________________________________________________
