42 C.F.R. Subpart R—Medicare Contract Appeals
Title 42 - Public Health
Source: 50 FR 1346, Jan. 10, 1985, unless otherwise noted.
This subpart establishes the procedures for making and reviewing the following initial determinations: (a) A determination that an HMO or CMP is not qualified to enter into a contract with CMS under section 1876 of the Act. (b) A determination that an HMO or CMP is qualified only for a reasonable cost contract. (c) A determination to terminate, or to refuse to renew, a contract with an HMO or CMP because— (1) The HMO or CMP has failed substantially to carry out the terms of the contract; (2) The HMO or CMP is carrying out the contract in a manner that is inconsistent with the efficient and effective administration of section 1876 of the Act; (3) The HMO or CMP no longer meets the applicable conditions necessary to qualify as an HMO or CMP under section 1876 of the Act and this subpart; or (4) The HMO or CMP has failed to comply with the composition of enrollment requirements specified in §417.413(d). [50 FR 1346, Jan. 10, 1985, as amended at 56 FR 46572, Sept. 13, 1991; 58 FR 38080, July 15, 1993] Administrative actions that are not initial determinations under this subpart include, but are not limited to, CMS's refusal to renew a contract with an HMO or CMP when the refusal is not based on the causes specifed in §417.640(c). [50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38080, July 15, 1993] (a) When CMS makes an initial determination, it gives the HMO or CMP written notice. (b) The notice specifies— (1) The reasons for the determination; and (2) The HMO's or CMP's right to request reconsideration. (c) CMS mails the notice to the HMO or CMP at least 90 days before the end of the contract period, or in the case of termination, at least 90 days before the effective date of the termination. [50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38083, July 15, 1993; 60 FR 46234, Sept. 6, 1995] The initial determination is final and binding on all parties unless— (a) It is reconsidered in accordance with §§417.648 through 417.658; (b) In the case of an initial determination described in §417.640(c), a request for a hearing is filed; or (c) It is revised as a result of a reopening under §417.692. (a) Reconsideration is the first step for appealing an organization determination specified in §417.640(a) or (b). (b) CMS reconsiders either of the specified determinations if the HMO or CMP files a written request in accordance with §417.650. [60 FR 46234, Sept. 6, 1995] (a) Method and place for filing a request. A request for reconsideration must be made in writing and filed with any CMS office. (b) Time for filing a request. Except as provided in paragraph (c) of this section, the request for reconsideration must be filed within 60 days from the date of the notice of the initial determination. (c) Extension of time to file a request. CMS may, in response to a party's written petition showing good cause, accept a request for reconsideration after the expiration of the 60 day period. (d) Proper party to file a request. Only an authorized official of the entity that was a party to an initial determination may file the request for reconsideration. (e) Withdrawal of a request. A request for reconsideration may be withdrawn by the party who filed the request at any time before the notice of the reconsidered determination is mailed. The request for withdrawal must be in writing and filed with CMS. If CMS approves, the request for reconsideration is withdrawn. CMS provides the parties to the reconsideration reasonable opportunity to present as evidence any documents or written statements that are relevant and material to the matters at issue. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] A reconsidered determination is a new determination that— (a) Is based on a review of the initial determination, the evidence and findings upon which that was based, and any other written evidence submitted before notice of the reconsidered determination is mailed, including facts relating to the status of the entity subsequent to the initial determination; and (b) Affirms, reverses, or modifies the initial determination. (a) CMS gives the parties written notice of the reconsidered determination. (b) The notice— (1) Contains findings with respect to the HMO's or CMP's qualifications to enter into a contract with CMS under section 1876 of the Act; (2) States the specific reasons for the reconsidered determination; and (3) Informs the party of its right to a hearing if it is dissatisfied with the determination. [60 FR 46234, Sept. 6, 1995] A reconsidered determination is final and binding on all parties unless a request for a hearing is filed in accordance with §417.662 or it is revised in accordance with §417.692. The following parties are entitled to a hearing: (a) An entity that has been determined in a reconsidered determination to be unqualified to enter into a contract with CMS under section 1876 of the Act. (b) An HMO or CMP that has been determined in a reconsidered determination to be qualified only for a reasonable cost contract. (c) An HMO or CMP whose contract with CMS has been terminated or has not been renewed as a result of an initial determination as provided in §417.640(c). [50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38083, July 15, 1993] (a) Method and place for filing a request. A request for a hearing must be made in writing and filed by an authorized official of the entity or HMO or CMP that was the party to the determination under appeal. The request for a hearing must be filed with any CMS office. (b) Time for filing a request. Except as provided in paragraph (c) of this section, a request for a hearing must be filed within 60 days after the date of receipt of the notice of initial or reconsidered determination. (c) Extension of time to file a request. If good cause is shown, the 60-day period to request a hearing may be extended by CMS. (d) Parties to a hearing. The parties to a hearing must be— (1) The parties described in §417.660; (2) At the discretion of the hearing officer, any interested parties who make a showing that their rights may be prejudiced by the decision to be rendered at the hearing; and (3) CMS. [50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38083, July 15, 1993] When a request for a hearing with respect to an initial determination is filed timely— (a) The effective date of the initial determination to terminate a contract with an HMO or CMP will be postponed until a hearing decision is reached; and (b) The current contract will be extended at the end of the contract period (in the case of a determination not to renew) only— (1) If CMS finds that an extension of the contract will be consistent with the purpose of section 1876 of the Act; and (2) For such period as CMS and the HMO or CMP agree. [50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38083, July 15, 1993] CMS designates a hearing officer to conduct the hearing. The hearing officer need not be an ALJ. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] (a) A hearing officer may not conduct a hearing in a case in which he or she is prejudiced or partial to any party or has any interest in the matter pending for decision. (b) A party to the hearing who objects to the designated hearing officer must notify that officer in writing at the earliest opportunity. (c) The hearing officer must consider the objections, and may, at his or her discretion, either proceed with the hearing or withdraw. (1) If the hearing officer withdraws, CMS designates another hearing officer to conduct the hearing. (2) If the hearing officer does not withdraw, the objecting party may, after the hearing, present objections and request that the officer's decision be revised or a new hearing be held before another hearing officer. The objections must be submitted to CMS. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] (a) The hearing officer fixes a time and place for the hearing and sends written notice to the parties. The notice also informs the parties of the general and specific issues to be resolved and information about the hearing procedure. (b) The hearing officer may, on his or her own motion, or at the request of a party, change the time and place for the hearing. The hearing officer may adjourn or postpone the hearing. (c) The hearing officer will give the parties reasonable notice of any change in the time or place of hearing, or of adjournment or postponement. [50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38081, July 15, 1993; 60 FR 46234, Sept. 6, 1995] A party may appoint as its representative at the hearing anyone not disqualified or suspended from acting as a representative before CMS or otherwise prohibited by law. (a) A representative appointed and qualified in accordance with §417.672 may, on behalf of the represented party— (1) Give or accept any notice or request pertinent to the proceedings set forth in this subpart; (2) Present evidence and allegations as to facts and law in any proceedings affecting that party; and (3) Obtain information to the same extent as the party. (b) A notice or request sent to the representative has the same force and effect as if it had been sent to the party. (a) The hearing is open to the parties and to the public. (b) The hearing officer inquires fully into all the matters at issue and receives in evidence the testimony of witnesses and any documents that are relevant and material. (c) The hearing officer provides the parties an opportunity to enter any objection to the inclusion of any document. (d) The hearing officer decides the order in which the evidence and the arguments of the parties are presented and the conduct of the hearing. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] The hearing officer rules on the admissibility of evidence and may admit evidence that would be inadmissible under rules applicable to court procedures. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] (a) The hearing officer may examine the witnesses. (b) The parties or their representatives are permitted to examine their witnesses and cross-examine witnesses of other parties. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] (a) Prehearing discovery is permitted upon timely request of a party. (b) A request is timely if it is made before the beginning of the hearing. (c) A reasonable time for inspection and reproduction of documents is provided by order of the hearing officer. (d) The hearing officer's order on all discovery matters is final. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] The hearing officer may schedule a prehearing conference if he or she believes that a conference would more clearly define the issues. (a) A complete record of the proceedings at the hearing is made and transcribed and made available to all parties upon request. (b) The record may not be closed until a hearing decision has been issued. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] In exercising his or her authority, the hearing officer must comply with the provisions of title XVIII and related provisions of the Act, the regulations issued by CMS, and general instructions issued by CMS in implementing that Act. (a) As soon as practical after the close of the hearing, the hearing officer issues a written decision that— (1) Is based upon the evidence of record; and (2) Contains separately numbered findings of fact and conclusions of law. (b) The hearing officer provides a copy of the hearing decision to each party. (c) The hearing decision is final and binding unless it is reopened and revised in accordance with §417.692. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] (a) Initial or reconsidered determination. An initial or reconsidered determination may be reopened and revised by CMS upon its own motion within one year of the date of the notice of determination. (b) Decision of hearing officer. A decision of a hearing officer that is unfavorable to any party and is otherwise final may be reopened and revised by the hearing officer upon the officer's own motion within one year of the notice of the hearing decision. It may be reopened and revised by another hearing officer designated by CMS if the hearing officer who issued the decision is unavailable. (c) Notices. (1) The notice of reopening and of any revisions following the reopening is mailed to the parties. (2) The notice of revision specifies the reasons for revisions. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995] The revision of an initial or reconsidered determination is binding unless a party files a written request for hearing of the revised determination in accordance with §417.662. [50 FR 1346, Jan. 10, 1985, as amended at 60 FR 46234, Sept. 6, 1995]
Title 42: Public Health
PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
Subpart R—Medicare Contract Appeals
§ 417.640 Determinations subject to appeal.
§ 417.642 Administrative actions that are not initial determinations.
§ 417.644 Notice of initial determination.
§ 417.646 Effect of initial determination.
§ 417.648 Reconsideration: Applicability.
§ 417.650 Request for reconsideration.
§ 417.652 Opportunity to submit evidence.
§ 417.654 Reconsidered determination.
§ 417.656 Notice of reconsidered determination.
§ 417.658 Effect of reconsidered determination.
§ 417.660 Right to a hearing.
§ 417.662 Request for hearing.
§ 417.664 Postponement of effective date of initial determination.
§ 417.666 Designation of hearing officer.
§ 417.668 Disqualification of hearing officer.
§ 417.670 Time and place of hearing.
§ 417.672 Appointment of representatives.
§ 417.674 Authority of representatives.
§ 417.676 Conduct of hearing.
§ 417.678 Evidence.
§ 417.680 Witnesses.
§ 417.682 Discovery.
§ 417.684 Prehearing.
§ 417.686 Record of hearing.
§ 417.688 Authority of hearing officer.
§ 417.690 Notice and effect of hearing decision.
§ 417.692 Reopening of initial or reconsidered determination or decision of a hearing officer.
§ 417.694 Effect of revised determination.
