42 C.F.R. § 405.1811

Right to contractor hearing; contents of, and adding issues to, hearing request

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(a) Right to hearing on final contractor determination. A provider (but no other individual, entity, or party) has a right to a contractor hearing, as a single provider appeal, with respect to a final contractor or Secretary determination for the provider's cost reporting period, if—

(1) The provider is dissatisfied with the contractor's final determination of the total amount of reimbursement due the provider, as set forth in the contractor's written notice pursuant to § 405.1803. Exception: If a final contractor determination is reopened under § 405.1885, any review by the contractor hearing officer must be limited solely to those matters that are specifically revised in the contractor's revised final determination (§§ 405.1887(d), 405.1889(b), and the “Exception” in § 405.1832(c)(2)(i)).

(2) The amount in controversy (as determined in accordance with § 405.1839) must be at least $1,000 but less than $10,000.

(3) Unless the provider qualifies for a good cause extension under § 405.1813, the date of receipt by the contractor of the provider's hearing request must be no later than 180 days after the date of receipt by the provider of the final contractor or Secretary determination.

(b) Contents of request for a contractor hearing on final contractor determination. The provider's request for a contractor hearing under paragraph (a) of this section must be submitted in writing to the contractor, and the request must include the elements described in paragraphs (b)(1) through (b)(3) of this section. If the provider submits a hearing request that does not meet the requirements of paragraph (b)(1), (b)(2), or (b)(3) of this section, the contractor hearing officer may dismiss with prejudice the appeal or take any other remedial action he or she considers appropriate.

(1) A demonstration that the provider satisfies the requirements for a contractor hearing as specified in paragraph (a) of this section, including a specific identification of the final contractor or Secretary determination under appeal.

(2) For each specific item under appeal, a separate explanation of why, and a description of how, the provider is dissatisfied with the specific aspects of the final contractor or Secretary determination under appeal, including an account of all of the following:

(i) Why the provider believes Medicare payment is incorrect for each disputed item (or, where applicable, why the provider is unable to determine whether Medicare payment is correct because it allegedly does not have access to underlying information concerning the calculation of its payment); and

(ii) How and why the provider believes Medicare payment should be determined differently for each disputed item.

(iii) If the provider self-disallows a specific item (as specified in § 413.24(j) of this chapter), an explanation of the nature and amount of each self-disallowed item, the reimbursement sought for the item, and why the provider self-disallowed the item instead of claiming reimbursement for the item.

(3) A copy of the final contractor or Secretary determination under appeal and any other documentary evidence the provider considers necessary to satisfy the hearing request requirements of paragraphs (b)(1) and (b)(2) of this section.

(c) Right to hearing based on untimely contractor determination. Notwithstanding the provisions of paragraph (a) of this section, a provider (but no other individual, entity, or party) has a right to a contractor hearing, as a single provider appeal, for specific items for a cost reporting period if—

(1) A final contractor determination for the provider's cost reporting period is not issued (through no fault of the provider) within 12 months after the date of receipt by the contractor of the provider's perfected cost report or amended cost report (as specified in § 413.24(f) of this chapter). The date of receipt by the contractor of the provider's perfected cost report or amended cost report is presumed to be the date of electronic delivery, or the date the contractor stamped “Received” on such cost report unless it is shown by a preponderance of the evidence that the contractor received the cost report on an earlier date.

(2) Unless the provider qualifies for a good cause extension under § 405.1813, the date of receipt by the contractor of the provider's hearing request is no later than 180 days after the expiration of the 12 month period for issuance of the final contractor determination (as determined in accordance with paragraph (c)(1) of this section); and

(3) The amount in controversy (as determined in accordance with § 405.1839) is at least $1,000 but less than $10,000.

(d) Contents of request for a contractor hearing based on untimely contractor determination. The provider's request for a contractor hearing under paragraph (c) of this section must be submitted in writing to the contractor, and the request must include the elements described in paragraphs (d)(1) through (d)(3) of this section. If the provider submits a hearing request that does not meet the requirements of paragraph (d)(1), (d)(2), or (d)(3) of this section, the contractor hearing officer may dismiss with prejudice the appeal or take any other remedial action he or she considers appropriate.

(1) A demonstration that the provider satisfies the requirements for a contractor hearing as specified in paragraph (c) of this section.

(2) An explanation (for each specific item at issue) of the following:

(i) Why the provider believes Medicare payment is incorrect for each disputed item (or, where applicable, why the provider is unable to determine whether Medicare payment is correct because it does not have access to underlying information concerning the calculation of Medicare payment).

(ii) How and why the provider believes Medicare payment must be determined differently for each disputed item.

(iii) If the provider self-disallows a specific item, a description of the nature and amount of each self-disallowed item and the reimbursement or payment sought for the item.

(3) A copy of any documentary evidence the provider considers necessary to satisfy the hearing request requirements of paragraphs (d)(1) and (d)(2) of this section.

(e) Adding issues to the hearing request. After filing a hearing request in accordance with paragraphs (a) and (b), or paragraphs (c) and (d), of this section, a provider may add specific Medicare payment issues to the original hearing request by submitting a written request to the contractor hearing officer, only if—

(1) The request to add issues complies with the requirements of paragraphs (a) and (b), or paragraphs (c) and (d), of this section as to each new specific item at issue.

(2) The specific items raised in the initial hearing request and the specific items identified in subsequent requests to add issues, when combined, satisfy the amount in controversy requirements of paragraph (a)(2) or paragraph (c)(3) of this section.

(3) The contractor hearing officer receives the provider's request to add issues no later than 60 days after the expiration of the applicable 180-day period prescribed in paragraph (a)(3) or paragraph (c)(2) of this section.

[73 FR 30244, May 23, 2008, as amended at 79 FR 50349, Aug. 22, 2014; 79 FR 59680, Oct. 3, 2014; 80 FR 70597, Nov. 13, 2015; 85 FR 59018, Sept. 18, 2020]

Notes of Decisions

Cited in 11 cases, 1982–2010 · leading case: Baptist Mem'l Hosp. v. Sebelius, 603 F.3d 57 (D.C. Cir. 2010).

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Baptist Mem'l Hosp. v. Sebelius, 603 F.3d 57 (D.C. Cir. 2010). · cites it 2× “For hospital cost reports which have been settled prior to the effective date of this ruling, but for which the hospital has a jurisdictionally proper appeal pending on this issue pursuant to either 42 CFR 405.1811 or 42 CFR 405.1835, these [eligible but unpaid] days may be…”

Baptist Mem'l Hosp. v. Johnson, 603 F. Supp. 2d 40 (D.D.C. 2009). “For hospital cost reports which have been settled prior to the effective date of this ruling, but for which the hospital has a jurisdictionally proper appeal pending on this issue pursuant to either 42 C.F.R. § 405.1811 or 42 C.F.R. § 405.1835 , these days may be included for…”

New Jersey Speech-Language-Hearing Ass'n v. Prudential Ins. Co. of Am., 551 F. Supp. 1024 (D.N.J. 1982). “A provider who is dissatisfied with such a denial may request a hearing before the intermediary, if the amount disputed is over $1000, 42 C.F.R. § 405.1811 , or before the Provider Reimbursement Review Board, if the disputed amount exceeds $10,000 and involves a cost report…”

Pac. Coast Med. Enter., Inc. v. United States, 3 Cl. Ct. 140 (Ct. Cl. 1983). “See 42 C.F.R. § 405.1811 (1978). For the year ending in 1973, plaintiff appealed to the Provider Reimbursement Review Board (the “PRRB”).”

Delaware Cnty. Mem'l Hosp. v. Sullivan, 836 F. Supp. 238 (E.D. Pa. 1991). “1889 (citing to 42 C.F.R. §§ 405.1811 , 1835, 1875 and 1877).”

Alexander Hosp., Inc. v. United States, 5 Cl. Ct. 62 (Ct. Cl. 1984). “Disallowances by plaintiffs’ fiscal intermediary were appealed to a Hearing Officer, who is an employee of the fiscal intermediary that made the adjustment ( 42 C.F.R. § 405.1811 ) and then to a “Special Review Officer” in the Health Care Financing Administration (HCFA) on…”

Bartlett Mem'l Med. Ctr., Inc. v. Thompson, 347 F.3d 828 (10th Cir. 2003). “For hospital cost reports which have been settled prior to the effective date of this ruling, but for which the hospital has a jurisdic-tionally proper appeal pending on this issue pursuant to either 42 C.”

St. Agnes Med. Ctr. v. Sebelius, 628 F. Supp. 2d 78 (D.D.C. 2009). “For hospital cost reports which have been settled prior to the effective date of this ruling, but for which the hospital has a jurisdictionally proper appeal pending on this issue pursuant to either 42 C.F.R. § 405.1811 or 42 C.F.R. § 405.1835 , these days may be included for…”

United States v. Seibert, 403 F. Supp. 2d 904 (S.D. Iowa 2005). “§ 1395oo(a); 42 C.F.R. §§ 405.1811 (outlining the procedures for requesting an intermediary hearing), .”

Nw. Hosp., Inc. v. United States, 4 Cl. Ct. 109 (Ct. Cl. 1983). “On appeal to and after a hearing before the Blue Cross Association’s Medicare Provider Appeals Committee (the “BCA”), see 42 C.F.R. § 405.1811 (1974), plaintiff showed that its administrator performed duties normally handled by several officers, that normal fringe benefits were…”

Bartlett Mem'l v. Thompson (10th Cir. 2003). “continued) for which the hospital has a jurisdictionally proper appeal pending on this issue pursuant to either 42 C.F.R. § 405.1811 or 42 C.F.R. § 405.1835 , these days may be included for purposes of resolving the appeal.”

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