42 C.F.R. § 422.502 Evaluation and determination procedures.
Title 42 - Public Health
(a) Basis for evaluation and determination. (1) CMS evaluates an application for an MA contract on the basis of information contained in the application itself and any additional information that CMS obtains through other means such as on-site visits, public hearings, and any other appropriate procedures. (2) After evaluating all relevant information, CMS determines whether the applicant's application meets the applicable requirements of §422.501. (b) Use of information from a prior contracting period. If an MA organization has failed to comply with the terms of a previous contract with CMS under title XVIII of the Act, or has failed to complete a corrective action plan during the term of the contract, CMS may deny an application based on the applicant's failure to comply with that prior contract with CMS even if the contract applicant meets all of the current requirements. (c) Notice of determination. Within timeframes determined by CMS, it notifies each applicant that applies for an MA contract under this part of its determination and the basis for the determination. The determination is one of the following: (1) Approval of application. If CMS approves the application, it gives written notice to the applicant, indicating that it qualifies to contract as an MA organization. (2) Intent to deny. (i)If CMS finds that the applicant does not appear to be able to meet the requirements for an MA organization and/or has not provided enough information to evaluate the application, CMS gives the contract applicant notice of intent to deny the application for an MA contract and a summary of the basis for this preliminary finding. (ii) Within 10 days from the date of the intent to deny notice, the contract applicant must respond in writing to the issues or other matters that were the basis for CMS' preliminary finding and must revise its application to remedy any defects CMS identified. (3) Denial of application. If CMS denies the application, it gives written notice to the contract applicant indicating— (i) That the applicant is not qualified to contract as an MA organization under Part C of title XVIII of the Act; (ii) The reasons why the applicant is not qualified; and (iii) The applicant's right to request reconsideration in accordance with the procedures specified in subpart N of this part. (d) Oversight of continuing compliance. (1) CMS oversees an MA organization's continued compliance with the requirements for an MA organization. (2) If an MA organization no longer meets those requirements, CMS terminates the contract in accordance with §422.510. [70 FR 4736, Jan. 28, 2005]
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart K—Contracts With Medicare Advantage Organizations
§ 422.502 Evaluation and determination procedures.
