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Title 42: Public Health
CHAPTER IV: CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)
SUBCHAPTER B: MEDICARE PROGRAM
PART 422: MEDICARE ADVANTAGE PROGRAM
Subpart M: Grievances, Organization Determinations and Appeals
422.600 - Right to a hearing.
(a) If the amount remaining in controversy after reconsideration meets the threshold requirement established annually by the Secretary, any party to the reconsideration (except the MA organization) who is dissatisfied with the reconsidered determination has a right to a hearing before an ALJ.
(b) The amount remaining in controversy, which can include any combination of Part A and Part B services, is computed in accordance with part 405 of this chapter.
(c) If the basis for the appeal is the MA organization's refusal to provide services, CMS uses the projected value of those services to compute the amount remaining in controversy.
[63 FR 35107, June 26, 1998, as amended at 70 FR 4740, Jan. 28, 2005]
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