42 CFR 426.560 - Effect of the Board's decision.
§ 426.560
Effect of the Board's decision.
(a) Valid under the reasonableness standard.
If the Board finds that the provision (or provisions) of an NCD named in the complaint is (are) valid under the reasonableness standard, the aggrieved party may challenge the final agency action in Federal court.
(b) Not valid under the reasonableness standard.
If the Board finds that the provision (or provisions) of an NCD named in the complaint is (are) invalid under the reasonableness standard, then CMS instructs its contractor, M C organization, or other Medicare managed care organization to provide the following—
(1) Individual claim review.
(i)
If the aggrieved party's claim/appeal(s) was previously denied, the contractor, an M C organization, or another Medicare managed care organization must reopen the claim of the party who challenged the LCD and adjudicate the claim without using the provision(s) of the NCD that the Board found invalid.
(ii)
If a revised NCD is issued, contractors, M C organizations, and other Medicare managed care organizations must use the revised NCD in reviewing claim/appeal submissions or request for services delivered or services performed on or after the effective date of the revised NCD.
(iii)
If the aggrieved party who sought review has not yet submitted a claim, the contractor must adjudicate the claim without using the provision(s) of the NCD that the Board found invalid.
Title 42 published on 2012-10-01
no entries appear in the Federal Register after this date.
This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.
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