7213 IIDR qualifications~2.docx

Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM).

7213.6 - Qualifications of an Independent Informal Dispute Resolution Entity or Person(s) (Rev. 118, Issued: 06-12-14, Effective: 01-01-12, Implementation: 01-01-12) In order to be approved as an Independent IDR entity or person, whether it is a State agency or an outside organization contracted by the State agency, the entity or person must meet the following requirements:

Expertise and Training: The entity or person has an understanding of:

• Medicare and Medicaid program requirements including, but not limited to:

a) 42 CFR Part 483, Subpart B, and Part 488, Subparts A, E and F;

b) The State Operations Manual (SOM), including;

1) Chapter 7, Definitions and §§ 7212, 7213 and 7900;

2) Appendix PP, Appendix Q; and Appendix Z

• Applicable health care standards of practice, health care management, and/ or life safety code knowledge and experience, relevant to the disputed issues.

Impartiality and Transparency and Impartiality: The entity or person –

a) have no financial or other conflict of interest.

b) must Prior to any contract award, vendor must be approved by CMS through a review conducted by the State under section 1864 of the Act, or by an entity approved by the State and CMS; or

a) Vendor must be approved by CMS or its agent, in the case of surveys conducted only by Federal surveyors where the State Independent IDR process is not used, and which vendor has no conflict of interest, such as:

1) A component of an umbrella State agency provided that the component is organizationally separate from the State survey agency, or

2) An independent entity with a specific understanding of Medicare and Medicaid program requirements selected by the State and approved by CMS.

Examples of possible conflict of interest include, but are not limited to, individuals who:

a) Were employed by the State survey agency or the State ombudsman program within the past year;

b) Have a family member who is either a resident or an employee of the facility involved in the Independent IDR;

c) Is currently employed by the facility or organization involved in the Independent IDR;

d) Have worked within the past year as an employee, consultant or volunteer for the facility or a related corporation, involved in the Independent IDR;

e) Have ownership interest or currently serves or within the past year has served on the Board of Directors or Governing Body of a facility or organization involved in the Independent IDR; or

f) Have acted within the past year as legal counsel for or against the facility involved in the Independent IDR.