42 CFR 422.619 - How an MA organization must effectuate expedited reconsidered determinations.

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There are 4 Updates appearing in the Federal Register for 42 CFR Part 422. View below or at eCFR (GPOAccess)
§ 422.619 How an MA organization must effectuate expedited reconsidered determinations.
(a) Reversals by the MA organization. If on reconsideration of an expedited request for service, the MA organization completely reverses its organization determination, the MA organization must authorize or provide the service under dispute as expeditiously as the enrollee's health condition requires, but no later than 72 hours after the date the MA organization receives the request for reconsideration (or no later than upon expiration of an extension described in § 422.590(d)(2)).
(b) Reversals by the independent outside entity. If the MA organization's determination is reversed in whole or in part by the independent outside entity, the MA organization must authorize or provide the service under dispute as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date it receives notice reversing the determination. The MA organization must inform the independent outside entity that the organization has effectuated the decision.
(c) Reversals other than by the MA organization or the independent outside entity—
(1) General rule. If the independent outside entity's expedited determination is reversed in whole or in part by the ALJ, or at a higher level of appeal, the MA organization must authorize or provide the service under dispute as expeditiously as the enrollee's health condition requires, but no later than 60 days from the date it receives notice reversing the determination. The MA organization must inform the independent outside entity that the organization has effectuated the decision.
(2) Effectuation exception when the MA organization files an appeal with the Medicare Appeals Council. If the MA organization requests Medicare Appeals Council (the Board) review consistent with § 422.608, the MA organization may await the outcome of the review before it authorizes or provides the service under dispute. A MA organization that files an appeal with the Board must concurrently send a copy of its appeal request and any accompanying documents to the enrollee and must notify the independent outside entity that it has requested an appeal.
[65 FR 40331, June 29, 2000, as amended at 68 FR 50859, Aug. 22, 2003]

Title 42 published on 2014-10-01.

The following are only the Rules published in the Federal Register after the published date of Title 42.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

  • 2015-02-24; vol. 80 # 36 - Tuesday, February 24, 2015
    1. 80 FR 9629 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors: CMS-Identified Overpayments Associated With Submitted Payment Data; Corrections
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      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Correction of final rule.
      Effective Date: This document is effective February 24, 2015. Applicability Date: The corrections noted in this document and posted on the CMS Web site are applicable to payments for services furnished on or after January 1, 2015.
      42 CFR Parts 411, 412, 416, 419, 422, 423, and 424

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United States Code

Title 42 published on 2014-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 422 after this date.

  • 2015-02-24; vol. 80 # 36 - Tuesday, February 24, 2015
    1. 80 FR 9629 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors: CMS-Identified Overpayments Associated With Submitted Payment Data; Corrections
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Correction of final rule.
      Effective Date: This document is effective February 24, 2015. Applicability Date: The corrections noted in this document and posted on the CMS Web site are applicable to payments for services furnished on or after January 1, 2015.
      42 CFR Parts 411, 412, 416, 419, 422, 423, and 424