C.F.R. » Title 42 » 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 I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

42 C.F.R. § 405.1102

Request for Council review when ALJ or attorney adjudicator issues decision or dismissal

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(a)(1) A party to a decision or dismissal issued by an ALJ or attorney adjudicator may request a Council review if the party files a written request for a Council review within 60 calendar days after receipt of the ALJ's or attorney adjudicator's decision or dismissal.

(2) For purposes of this section, the date of receipt of the ALJ's or attorney adjudicator's decision or dismissal is presumed to be 5 calendar days after the date of the notice of the decision or dismissal, unless there is evidence to the contrary.

(3) The request is considered as filed on the date it is received by the entity specified in the notice of the ALJ's or attorney adjudicator's action.

(b) A party requesting a review may ask that the time for filing a request for Council review be extended if—

(1) The request for an extension of time is in writing;

(2) It is filed with the Council; and

(3) It explains why the request for review was not filed within the stated time period. If the Council finds that there is good cause for missing the deadline, the time period will be extended. To determine whether good cause exists, the Council uses the standards outlined at § 405.942(b)(2) and (3).

(c) A party does not have the right to seek Council review of an ALJ's or attorney adjudicator's remand to a QIC, affirmation of a QIC's dismissal of a request for reconsideration, or dismissal of a request for review of a QIC dismissal.

(d) For purposes of requesting Council review (§§ 405.1100 through 405.1140), unless specifically excepted, the term “party”, includes CMS where CMS has entered into a case as a party according to § 405.1012. The term, “appellant,” does not include CMS, where CMS has entered into a case as a party according to § 405.1012.

[82 FR 5122, Jan. 17, 2017]
Notes of Decisions
Cited in 11 cases (3 in the last 5 years), 2012–2024 · leading case: True Health Diagnostics, LLC v. Azar
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True Health Diagnostics, LLC v. Azar (2019) txed “§ 1395ff(b) ; 42 C.F.R. § 405.1102 (a) ). A provider or supplier may only seek review in a federal district court after a receiving a decision from the MAC.”
B & H Medical, LLC v. United States (2014) uscfc “1002 , or that if it received an ALJ decision, that it sought MAC review of such a decision, 42 C.F.R. § 405.1102 . Absent evidence that plaintiff has exhausted its administrative appeals and is eligible to request federal court review of its claim, the court cannot find that…”
Cypress Home Care, Inc. v. Azar (2018) txed “See 42 C.F.R. § 405.1102 . In a consolidated action dated April 28, 2016, the Council reversed the ALJ's decision as to the extrapolation, issued coverage decisions in favor of Cypress as to eight of the claims, and affirmed the denial of the remaining claims.”
True Health Diagnostics, LLC v. Azar (2019) txed “§ 1395ff(b) ; 42 C.F.R. § 405.1102 (a) ). A provider or supplier may only seek review in a federal district court after a receiving a decision from the MAC.”
Lewis v. Azar (2022) dcd “1000 (a)), and finally appeal any adverse ruling by the ALJ to the Medicare Appeals Council (the “Appeals Council”), see 42 C.F.R. § 405.1102 . The Appeals Council may then “decide on its own motion to review a decision or dismissal issued by an [ALJ],” id.”
Maka Hospice, Inc. v. Alex M. Azar, II (2019) cacd “); (3) a de novo 25 review and hearing before an Administrative Law Judge (“ALJ”) (42 C.”
Vein & Wellness Group, LLC v. Xavier Becerra (2024) ca4 “§ 1395ff(d)(2); 42 C.F.R. § 405.1102 . If the Secretary did not participate at the ALJ level, the MAC will hear his appeal only if the ALJ’s decision relied on an “error of law” or 4 USCA4 Appeal: 22-2253 Doc: 33 Filed: 06/20/2024 Pg: 5 of 15 “presents a broad policy or…”
Kantor v. Azar (2021) mdd “See 42 C.F.R. § 405.1102 (c) (“A party does not have the right to seek Council review of an ALJ’s .”
GLAD v. MEDICARE/NOVITAS SOLUTIONS (2020) njd “See 42 CFR § 405.1102 (a). * Only after the MAC issues a final order (which includes an order declining to review the matter) does the disposition become a final decision of the Secretary, entitling a still-dissatisfied party to bring an action in federal court.”
GLAD v. NOVITAS SOLUTIONS/MEDICARE (2020) njd “See 42 CFR § 405.1102 (a). * Only after the MAC issues a final order (which includes an order declining to review the matter) does the disposition become a final decision of the Secretary, entitling a still-dissatisfied party to bring an action in federal court.”
United Medical Healthcare, Inc. v. Department of Health & Human Services (2012) laed “See 42 C.F.R. § 405.1102 , et seq. The decision of the MAC is final and binding on all parties and is considered the final decision of the Secretary.”
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