TITLE 42 - PUBLIC HEALTH

CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER B - MEDICARE PROGRAM

PART 405 - FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED

subpart r - PROVIDER REIMBURSEMENT DETERMINATIONS AND APPEALS

405.1835 - Right to Board hearing.

  (a) Criteria. The provider (but no other individual, entity, or party) has a right to a hearing before the Board about any matter designated in 405.1801(a)(1), if: (1) An intermediary determination has been made with respect to the provider; and (2) The provider has filed a written request for a hearing before the Board under the provisions described in 405.1841(a)(1); and (3) The amount in controversy (as determined in 405.1839(a)) is $10,000 or more.

  (b) Prospective payment exceptions. Except with respect to matters for which administrative or judicial review is not permitted as specified in 405.1804, hospitals that are paid under the prospective payment system are entitled to hearings before the Board under this section if they otherwise meet the criteria described in paragraph (a) of this section.

  (c) Right to hearing based on late intermediary determination about reasonable cost. Notwithstanding the provisions of paragraph (a)(1) of this section, the provider also has a right to a hearing before the Board if an intermediary's determination concerning the amount of reasonable cost reimbursement due a provider is not rendered within 12 months after receipt by the intermediary of a provider's perfected cost report or amended cost report (as permitted or as required to furnish sufficient data for purposes of making such determinationsee 405.1803(a)) provided such delay was not occasioned by the fault of the provider.

[48 FR 39835, Sept. 1, 1983]