42 C.F.R. Subpart N—Medicare Contract Determinations and Appeals
Title 42 - Public Health
Source: 63 FR 35113, June 26, 1998, unless otherwise noted.
This subpart establishes the procedures for making and reviewing the following contract determinations: (a) A determination that an entity is not qualified to enter into a contract with CMS under Part C of title XVIII of the Act. (b) A determination to terminate a contract with an MA organization in accordance with §422.510(a). (c) A determination not to authorize a renewal of a contract with an MA organization in accordance with §422.506(b). (a) When CMS makes a contract determination, it gives the MA organization written notice. (b) The notice specifies— (1) The reasons for the determination; and (2) The MA organization's right to request reconsideration. (c) For CMS-initiated terminations, CMS mails notice 90 days before the anticipated effective date of the termination. For terminations based on initial determinations described at §422.510(a)(5), CMS immediately notifies the MA organization of its decision to terminate the organization's MA contract. (d) When CMS determines that it will not authorize a contract renewal, CMS mails the notice to the MA organization by May 1 of the current contract year. The contract determination is final and binding unless— (a) The determination is reconsidered in accordance with §§422.648 through 422.658; (b) A timely request for a hearing is filed under §422.662; or (c) The reconsideration decision is revised as a result of a reopening under §422.696. (a) Reconsideration is the first step for appealing a contract determination specified in §422.641. (b) CMS reconsiders the specified determinations if the contract applicant or the MA organization files a written request in accordance with §422.650. (c) Notice of any redetermination favorable to the MA organization applicant, including those resulting from a hearing or Administrator review conducted under this subpart, must be issued by July 15 for the contract in question to be effective on January 1 of the following year. [63 FR 35113, June 26, 1998, as amended at 65 FR 40331, June 29, 2000; 70 FR 4741, Jan. 28, 2005] (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. The request for reconsideration must be filed within 15 days from the date of the notice of the initial determination. (c) Proper party to file a request. Only an authorized official of the contract applicant or MA organization that was the subject of a contract determination may file the request for reconsideration. (d) Withdrawal of a request. The MA organization or contract applicant who filed the request for a reconsideration may withdraw it at any time before the notice of the reconsidered determination is mailed. The request for withdrawal must be in writing and filed with CMS. [63 FR 35113, June 26, 1998, as amended at 65 FR 40331, June 29, 2000] CMS provides the MA organization or contract applicant and the CMS official or officials who made the contract determination reasonable opportunity, not to exceed the timeframe in which an MA organization could choose to request a hearing as described at §422.662, to present as evidence any documents or written statements that are relevant and material to the matters at issue. [65 FR 40332, June 29, 2000] A reconsidered determination is a new determination that— (a) Is based on a review of the contract 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 MA organization subsequent to the contract determination; and (b) Affirms, reverses, or modifies the initial determination. (a) CMS gives the MA organization or contract applicant written notice of the reconsidered determination. (b) The notice— (1) Contains findings with respect to the contract applicant's qualifications to enter into, or the MA organization's qualifications to remain under, a contract with CMS under Part C of title XVIII of the Act; (2) States the specific reasons for the reconsidered determination; and (3) Informs the MA organization or contract applicant of its right to a hearing if it is dissatisfied with the determination. [63 FR 35113, June 26, 1998, as amended at 65 FR 40332, June 29, 2000] A reconsidered determination is final and binding unless a request for a hearing is filed in accordance with §422.662 or it is revised in accordance with §422.696. The following parties are entitled to a hearing: (a) A contract applicant that has been determined in a reconsidered determination to be unqualified to enter into a contract with CMS under Part C of title XVIII of the Act. (b) An MA organization whose contract with CMS has been terminated or has not been renewed as a result of a contract determination as provided in §422.641. [63 FR 35113, June 26, 1998, as amended at 65 FR 40332, June 29, 2000] (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 contract applicant or MA organization 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. A request for a hearing must be filed within 15 days after the date of the reconsidered determination. (c) Parties to a hearing. The parties to a hearing must be— (1) The parties described in §422.660; (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. [63 FR 35113, June 26, 1998, as amended at 65 FR 40332, June 29, 2000] (a) CMS postpones the proposed effective date of the contract determination to terminate a contract with an MA organization until a hearing decision is reached and affirmed by the Administrator following review under §422.692 in instances where an MA organization requests review by the Administrator; and (b) CMS extends the current contract 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 this part; and (2) For such period as CMS and the MA organization agree. (c) Exception: A contract terminated in accordance with §422.510(a)(5) will be immediately terminated and will not be postponed if a hearing is requested. CMS designates a hearing officer to conduct the hearing. The hearing officer need not be an ALJ. (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 in writing to CMS. (a) The hearing officer fixes a time and place for the hearing, which is not to exceed 30 days from the receipt of the request 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 time or place of hearing, or of adjournment or postponement. A party may appoint as its representative at the hearing anyone not disqualified or suspended from acting as a representative before the Secretary or otherwise prohibited by law. (a) A representative appointed and qualified in accordance with §422.672 may, on behalf of the represented party— (1) Gives or accepts any notice or request pertinent to the proceedings set forth in this subpart; (2) Presents evidence and allegations as to facts and law in any proceedings affecting that party; and (3) Obtains 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. The hearing officer rules on the admissibility of evidence and may admit evidence that would be inadmissible under rules applicable to court procedures. (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. (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. 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. 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 the Secretary, and general instructions issued by CMS in implementing the 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 reversed or modified by the Administrator following review under §422.692, or reopened and revised in accordance with §422.696. (a) Request for review by Administrator. An MA organization that has received a hearing decision upholding a contract termination determination may request review by the Administrator within 15 days of receiving the hearing decision as provided under §422.690(b). (b) Review by the Administrator. The Administrator shall review the hearing officer's decision, and determine, based upon this decision, the hearing record, and any written arguments submitted by the MA organization, whether the termination decision should be upheld, reversed, or modified. (c) Decision by the Administrator. The Administrator issues a written decision, and furnishes the decision to the MA organization requesting review. A decision by the Administrator under section 422.692 is final and binding unless it is reopened and revised in accordance with §422.696. (a) Initial or reconsidered determination. CMS may reopen and revise an initial or reconsidered determination 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. Another hearing officer designated by CMS may reopen and revise the decision if the hearing officer who issued the decision is unavailable. (c) Decision of Administrator. A decision by the Administrator that is otherwise final may be reopened and revised by the Administrator upon the Administrator's own motion within one year of the notice of the Administrator's decision. (d) 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. The revision of a contract or reconsidered determination is binding unless a party files a written request for hearing of the revised determination in accordance with §422.662.
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart N—Medicare Contract Determinations and Appeals
§ 422.641 Contract determinations.
§ 422.644 Notice of contract determination.
§ 422.646 Effect of contract determination.
§ 422.648 Reconsideration: Applicability.
§ 422.650 Request for reconsideration.
§ 422.652 Opportunity to submit evidence.
§ 422.654 Reconsidered determination.
§ 422.656 Notice of reconsidered determination.
§ 422.658 Effect of reconsidered determination.
§ 422.660 Right to a hearing.
§ 422.662 Request for hearing.
§ 422.664 Postponement of effective date of a contract determination when a request for a hearing with respect to a contract determination is filed timely.
§ 422.666 Designation of hearing officer.
§ 422.668 Disqualification of hearing officer.
§ 422.670 Time and place of hearing.
§ 422.672 Appointment of representatives.
§ 422.674 Authority of representatives.
§ 422.676 Conduct of hearing.
§ 422.678 Evidence.
§ 422.680 Witnesses.
§ 422.682 Discovery.
§ 422.684 Prehearing.
§ 422.686 Record of hearing.
§ 422.688 Authority of hearing officer.
§ 422.690 Notice and effect of hearing decision.
§ 422.692 Review by the Administrator.
§ 422.694 Effect of Administrator's decision.
§ 422.696 Reopening of contract or reconsidered determination or decision of a hearing officer or the Administrator.
§ 422.698 Effect of revised determination.
