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. § 405.1132

Request for escalation to Federal court

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(a) If the Council does not issue a decision or dismissal or remand the case to an ALJ or attorney adjudicator within the adjudication period specified in § 405.1100, or as extended as provided in this subpart, the appellant may request that the appeal, other than an appeal of an ALJ or attorney adjudicator dismissal, be escalated to Federal district court. Upon receipt of a request for escalation, the Council may—

(1) Issue a decision or dismissal or remand the case to an ALJ or attorney adjudicator, if that action is issued within the latter of 5 calendar days of receipt of the request for escalation or 5 calendar days from the end of the applicable adjudication time period set forth in § 405.1100; or

(2) If the Council is not able to issue a decision or dismissal or remand as set forth in paragraph (a)(1) of this section, it will send a notice to the appellant acknowledging receipt of the request for escalation and confirming that it is not able to issue a decision, dismissal or remand order within the statutory time frame.

(b) A party may file an action in a Federal district court within 60 calendar days after the date it receives the Council's notice that the Council is not able to issue a final decision, dismissal order, or remand order unless the party is appealing an ALJ or attorney adjudicator dismissal.

[70 FR 11472, Mar. 8, 2005, as amended at 74 FR 65338, Dec. 9, 2009; 82 FR 5124, Jan. 17, 2017]
Notes of Decisions
Cited in 32 cases (23 in the last 5 years), 2014–2026 · leading case: Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018).
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Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018). “§§ 405(g), (h) ; 42 C.F.R. § 405.1132 . Neither has occurred here, and Family Rehab concedes that its claims "arise under" the Medicare Act.”
Accident, Injury & Rehab v. Alex Azar, II, 943 F.3d 195 (4th Cir. 2019). “§ 1395ff(d)(3)(B); see also 42 C.F.R. § 405.1132 . 816 F.3d at 53–54 (alterations in original).”
Cumberland Cnty. Hosp. Sys., Inc. v. Burwell, 816 F.3d 48 (4th Cir. 2016). “§ 1395ff(d)(3)(B); see also 42 C.F.R. § 405.1132 . In sum, in order to exhaust the administrative process for reimbursement of Medicare services, a healthcare provider must present the claim in the first, instance to.”
Popkin v. Burwell, 172 F. Supp. 3d 161 (D.D.C. 2016). · cites it 2× “42 C.F.R. § 405.1132 . .Most of the work done by Medicare Administrative Contractors consists of audits on providers after payments have been made to them.”
Am. Hosp. Ass'n v. Sebelius, 76 F. Supp. 3d 43 (D.D.C. 2014). “§ 1395ff(d)(3)(B); 42 C.F.R. § 405.1132 (b); 42 C.F.R. § 405.”
D&G Holdings, LLC v. Sylvia Mathews Burwell, 156 F. Supp. 3d 798 (W.D. La. 2016). “and render a decision on such hearing by not later than the end of the 90-day period beginning on the date a request for hearing has been timely filed,” “the party requesting the hearing may request a review by the Departmental Appeals Board of the Department of Health and Human…”
B & H Med., LLC v. United States, 116 Fed. Cl. 671 (Fed. Cl. 2014). “Judicial review in Federal District Court (if the amount of the claim is greater than $1,000) ( 42 C.F.R. §§ 405.1132 -.1136). Def.’s Mot.”
Sanderson v. Sec'y of the United States Dep't of Health & Human Servs. (D. Kan. 2022). · cites it 5× “16 Under 42 C.F.R. § 405.1132 , if the MAC does not issue a decision, dismissal, or remand back to the ALJ within 90 days or as extended “as provided in this subpart,” the appellant may request that the appeal be escalated to Federal district court.”
Integrity Soc. Work Servs., LCSW, LLC v. AZAR (E.D.N.Y 2021). · cites it 3× “” 42 C.F.R. § 405.1132 (a)(2). The appellant may then bring an action in federal district court within sixty days.”
Prosser v. Becerra (E.D. Wis. 2020). · cites it 2× “42 C.F.R. § 405.1132 (a). If a beneficiary wishes to challenge a decision of the Council (or receives notice from the Council that it is unable to review the claim), the beneficiary has 60 days to file in federal district court.”
Edwin R. Banks v. Sec'y of Health & Human Servs. (11th Cir. 2021). “See 42 C.F.R. § 405.1132 . Banks argued collateral estoppel prevented the Secretary from relitigating the issue of TTFT coverage in the claims decided by ALJ Kelton, because ALJ Gulin’s decisions conclusively determined an issue litigated between the same parties and became…”
Edwin R. Banks v. Sec'y of Health & Human Servs. (11th Cir. 2021). “See 42 C.F.R. § 405.1132 . Banks argued collateral estoppel prevented the Secretary from relitigating the issue of TTFT coverage in the claims decided by ALJ Kelton, because ALJ Gulin’s decisions conclusively determined an issue litigated between the same parties and became…”
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