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Based on the continued non-compliance from a survey cycle beginning on November 19,
2015, CMS has involuntarily terminated the provider agreement with Rosebud Indian Health
Service Hospital. As a result of the serious nature and circumstances of this involuntary
termination, should Rosebud Indian Health Service Hospital desire to re-enter the Medicare
Program as a provider of hospital services, Rosebud Indian Health Services must provide
CMS with reasonable assurance of its capacity to maintain compliance with the Medicare
requirements for certification, as provided for in the Social Security Act 1866 (c) (1) and in
regulation 42 CFR 489.57.
As communicated to you in CMS' notification to Rosebud Indian Health Service Hospital,
dated December 4, 2015, the Medicare program will not make payment for covered hospital
services furnished to patients whose plan of treatment was established on or after the
termination date. For Medicare patients whose plan of treatment was established prior to
March 16, 2016, payment for covered services may be made for up to 30 calendar days after
the date of termination. (See 42 C.F.R. 489.55(a)).
Termination of your participation in the Medicare program will also result in termination of
your Medicaid agreement. CMS is forwarding a copy of this letter to the South Dakota
Medicaid State Agency. CMS is also sending a copy of this letter to the Medicare
Administrative Contractor, Novitas Solutions, Inc. You should contact that office to make
arrangements for filing a final cost report, in the event that you have admitted and billed for
any Medicare patients.
Appeal Rights
Ifyou disagree with the findings ofnoncompliance cited in the survey conducted
February 9-12, 2016, you or your legal representative may request a hearing before an
administrative law judge ofthe Department ofHealth and Human Services, Departmental
Appeals Board. Procedures governing this process are set out in Federal regulations at
42 C.F.R. 498.40, et seq. You must file the hearing request electronically by using the
Departmental Appeals Board's Electronic Filing System (DABE-File) at
https://dab.efile.hhs.gov no later than sixty (60) days from the date ofreceipt of this letter.
Also, you must send a complete copy of the hearing request, all written communications
concerning this survey and any other supporting documentation to Linda Bedker RN,
MN, MPH, CAPTAIN, U.S.P.H.S., Manager; Certification and Enforcement Branch;
Centers for Medicare & Medicaid Services; Denver Regional Office; 1961 Stout Street,
Room 08-148; Denver, Colorado 80294, or via email to
Linda. Bedker@cms.hhs.gov
Requests for a hearing submitted by U.S . mail or commercial carrier are no longer
accepted as of October 1, 2014, unless you do not have access to a computer or Internet
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service. In those circumstances you may call the Civil Remedies Division to request a
waiver from e-filing and provide an explanation as to why you cannot file electronically or
you may mail a written request for a waiver along with your written request for a hearing.
A written request for a hearing must be filed no later than sixty (60) days f rom the date of
receipt of this letter, to the Department ofHealth & Human Services; Departmental
Appeals Board, MS 6132; Director, Civil Remedies Division; 330 Independence A venue,
S.W.; Cohen Building-Room G-644; Washington, D.C. 20201; (202) 565-9462.
A request for a hearing should identify the specific issues and the findings of fact and
conclusions of law with which you disagree. It should also specify the basis for
contending that the findings and conclusions are incorrect. You may be represented by
counsel at a hearing at your own expense.
If you have any question regarding this matter, please contact CDR Kimmine Hudson at (303)
844-7127, email: kimmine.hudson@cms.hhs.gov.
Sincerely,
~
ic~
Associate Regional Administrator
Western Division of Survey and Certification
Enclosures:
23 day Termination-U (November 23 , 2015)
IJ Abated (December 11 , 2015)
90 day Notice Intent to Terminate (December 4, 2015)
Extend Termination Date (February 12, 2016)
CMS FORM 2567 (February 22, 2016)
Copies via e-mail to:
[HS Great Plains Area Office
South Dakota Department of Health, Office of Health Care Facilities, Licensure & Certification
Novitas Solutions, Inc
CMS Denver Regional Office, SB & CEB
CMS Denver Regional Office, Office of the Regional Administrator
Office of the General Counsel, Denver Office
CMS Denver Regional Office, Medicaid Program Management Branch
CMS Denver Regional Office, Medicaid Financial Management Branch
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