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 R—Provider Reimbursement Determinations and Appeals

42 C.F.R. § 405.1804

Matters not subject to administrative and judicial review under prospective payment

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Neither administrative nor judicial review is available for controversies about the following matters:

(a) The determination of the requirement, or the proportional amount, of the budget neutrality adjustment in the prospective payment rates required under section 1886(e)(1) of the Social Security Act.

(b) The establishment of—

(1) Diagnosis related groups (DRGs);

(2) The methodology for the classification of inpatient discharges within the DRGs; or

(3) Appropriate weighting factors that reflect the relative hospital resources used with respect to discharge within each DRG.

[49 FR 322, Jan. 1, 1984, as amended at 78 FR 75195, Dec. 10, 2013]
Notes of Decisions
Cited in 3 cases (1 in the last 5 years), 1993–2024 · leading case: St. Marys Reg'l Med. Ctr. v. Xavier Becerra (D.D.C. 2024).
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St. Marys Reg'l Med. Ctr. v. Xavier Becerra (D.D.C. 2024). · cites it 2× “42 CFR § 405.1804 . These provisions barring review of the Secretary’s budget neutrality adjustments are hereafter referred to as the “Preclusion Provisions.”
OSF Healthcare Sys. v. Sullivan, 820 F. Supp. 390 (C.D. Ill. 1993). “See also 42 C.F.R. § 405.1804 regarding matters not subject to administrative and judicial review.”
Adirondack Med. Ctr. v. Sebelius (D.D.C. 2012). “PRRB predicted that its jurisdictional decision would be reversed because, at least since 2008, the Secretary has maintained that PRRB’s interpretation of 42 C.F.R. § 405.1804 as precluding jurisdiction is in error.”
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