42 C.F.R. § 405.1809

Contractor hearing procedures

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(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 Community Health Services Inc. v. U.S. Department of Health & Human Services

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Three Lower Counties Community Health Services Inc. v. U.S. Department of Health & Human Services (2007) dcd “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 General Hospital, Inc. v. United States (1982) cc “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 Community Hospital v. United States (1982) cc “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 Management Corp. v. United States Department of Health & Human Services (1991) ohsd · 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 Maintenance Organization, Inc. v. Price (2019) dcd “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 Hospital v. United States (1983) cc “42 C.F.R. § 405.1809 . Until 1976, Medicare reimbursement regulations were codified in Volume 20 of the Code of Federal Regulations.”

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