42 C.F.R. § 405.1807
Effect of contractor determination
The determination shall be final and binding on the party or parties to such determination unless:
(a) A contractor hearing is requested in accordance with § 405.1811 and a contractor hearing decision rendered in accordance with § 405.1831; or
(b) The contractor determination is revised in accordance with § 405.1885; or
(c) A Board hearing is requested in accordance with § 405.1835 and a hearing decision rendered pursuant thereto.
Notes of Decisions
Cited in 18
cases (1 in the last 5 years), 1987–2021 · leading case: Regions Hosp. v. Shalala, 522 U.S. 448 (1998).
Regions Hosp. v. Shalala, 522 U.S. 448 (1998). “Finally, the Hospital argues that because 42 CFR §§ 405.1807 and 405.1885(a) (1996) render an intermediary's determination "final and binding" after three years, the Secretary's reaudit regulation violates principles of issue preclusion.”
Little Co. of Mary Hosp. v. Sebelius, 587 F.3d 849 (7th Cir. 2009). “42 C.F.R. § 405.1807 (2009). However, under 42 C.”
Kaiser Found. Hospitals v. Sebelius, 828 F. Supp. 2d 193 (D.D.C. 2011). “The hospital has 180 days from receipt of the NPR to request a review by the Provider Reimbursement Review Board (PRRB).”
Kaiser Found. Hospitals v. Kathleen Sebelius, 708 F.3d 226 (D.C. Cir. 2013). “See 42 C.F.R. § 405.1807 (c). The reimbursement- determination may nevertheless be reopened — upon a provider’s request or at the intermediary’s own initiative — within three years of the date of the NPR.”
Allina Health Servs. v. Sebelius, 904 F. Supp. 2d 75 (D.D.C. 2012). “§ 1395oo; 42 C.F.R. §§ 405.1807 , 405.1835. The PRRB’s determination as to an appeal is considered the final agency action unless the Secretary, on her own motion, reverses, affirms, or modifies that decision.”
United States v. Tenet Healthcare Corp., 343 F. Supp. 2d 922 (C.D. Cal. 2004). “See 42 C.F.R. § 405.1807 . Within three years of the decision, a provider may seek to reopen the administrative determination; likewise, the intermediary, Board or Secretary may, on its own motion, reopen the proceedings.”
Grp. Health Inc. v. Blue Cross Ass'n, 739 F. Supp. 921 (S.D.N.Y. 1990). “Nothing in the statute or the regulations promulgated pursuant to the statute require the fiscal intermediary to consult with HHS or the Secretary prior to rendering its opinion on a reimbursement question.”
St. Thomas Hosp. v. Sebelius, 705 F. Supp. 2d 905 (M.D. Tenn. 2010). “42 C.F.R. § 405.1807 . Nevertheless, within three years of the NPR, the fiscal intermediary may reopen “findings on matters at issue in a determination or decision” based upon its own initiative, or at the request of the provider.”
Grp. Health Inc. v. United States, 662 F. Supp. 753 (S.D.N.Y. 1987). “42 C.F.R. § 405.1807 (1984). For a period of three years, such decisions remain subject to being reopened and revised at the direction of the Secretary.”
Decatur Cnty. Gen. Hosp. v. Johnson, 602 F. Supp. 2d 176 (D.D.C. 2009). “§ 1395oo(a); see also 42 C.F.R. §§ 405.1807 , 405.1835. By request, or on its own motion, a decision by the Board is subject to review by the Secretary’s delegate, the Administrator of CMS.”
Flint v. Alex M. Azar, II (D.D.C. 2020). “See 42 C.F.R. § 405.1807 . After an NPR becomes final, however, a MAC may reopen it “with respect to specific findings on matters at issue in [the initial NPR],” either at the provider’s request or on the MAC’s own initiative.”
Firsthealth Moore Reg'l Hosp. v. Azar (D.D.C. 2021). “’s Opp’n at 4 (quoting 42 C.F.R. § 405.1807 ). MAC reopening and PRRB appeals may proceed simultaneously, since a MAC “may reopen .”
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