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. § 405.1809

Contractor hearing procedures

Read at: eCFRecfr.gov CornellLII GovInfogovinfo.gov CasesGoogle Scholar

(a) Hearings. Each contractor must establish and maintain written procedures for contractor hearings, in accordance with the regulations in this subpart, for resolving issues that may arise between the contractor and a provider concerning the amount of reasonable cost reimbursement, or prospective payment due the provider (except as provided in § 405.1804) under the Medicare program. The procedures must provide for a hearing on the contractor determination contained in the notice of program reimbursement (§ 405.1803), if the provider files a timely request for a hearing.

(b) Amount in controversy. In order for a contractor to grant a hearing, the following dates and amounts in controversy apply:

(1) For cost reporting periods ending prior to June 30, 1973, the amount of program reimbursement in controversy must be at least $1000.

(2) For cost reporting periods ending on or after June 30, 1973, the amount of program reimbursement in controversy must be at least $1000 but less than $10,000.

[48 FR 39835, Sept. 1, 1983, as amended at 49 FR 323, Jan. 1, 1984]
Notes of Decisions
Cited in 6 cases, 1982–2019 · leading case: Three Lower Counties Cmty. Health Servs. Inc. v. U.S. Dep't of Health & Human Servs., 517 F. Supp. 2d 431 (D.D.C. 2007).
Sort: Relevance Newest Treatment
Three Lower Counties Cmty. Health Servs. Inc. v. U.S. Dep't of Health & Human Servs., 517 F. Supp. 2d 431 (D.D.C. 2007). “The FQHC may request a hearing before the intermediary if the amount in controversy is at least $1,000, but less than $10,000, 42 C.F.R. § 405.1809 , or before the Provider Reimbursement Review Board (“PRRB” or the “Board”) if the amount in controversy is more than $10,000.”
Spokane Valley Gen. Hosp., Inc. v. United States, 231 Ct. Cl. 550 (Ct. Cl. 1982). “42 C.F.R. § 405.1809 . Although the Blue Cross hearing officer who reviewed Spokane Valley’s claims for 1971-72 was not bound by the *555 Board’s determination of the 1973-75 claims, he adopted the Board’s "reasoning and conclusions.”
Valley View Cmty. Hosp. v. United States, 230 Ct. Cl. 581 (Ct. Cl. 1982). “The government points out that the plaintiffs failed to appeal Blue Cross’ adjustments in Valley View’s cost reports for those years to the intermediary hearing officer, as 42 C.F.R. §405.1809 (1980) required. It argues that failure to exhaust administrative remedies bars the…”
Westchester Mgmt. Corp. v. United States Dep't of Health & Human Servs., 790 F. Supp. 159 (S.D. Ohio 1991). · cites it 2× “If the amount in controversy in $10,000 or more, a provider may request a hearing to review the intermediary’s decision before the Provider Reimbursement Review Board (PRRB). 42 U.”
Rocky Mountain Health Maint. Org., Inc. v. Price (D.D.C. 2019). “See 42 C.F.R. §§ 405.1809 (2007). Second, such hearings were “conducted by a hearing officer or panel of hearing officers designated by the intermediary,” not the Administrator.”
Beverly Glen Hosp. v. United States, 3 Cl. Ct. 467 (Ct. Cl. 1983). “42 C.F.R. § 405.1809 . Until 1976, Medicare reimbursement regulations were codified in Volume 20 of the Code of Federal Regulations.”
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.