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. § 405.1869

Scope of Board's authority in a hearing decision

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(a) If the Board has jurisdiction to conduct a hearing on a specific matter at issue under section 1878(a) or (b) of the Act and § 405.1840 of this subpart, and the legal authority to fully resolve the matter in a hearing decision (as described in §§ 405.1842(f), 405.1867, and 405.1871 of this subpart), section 1878 of the Act, and paragraph (a) of this section give the Board the power to affirm, modify, or reverse the contractor's findings on each specific matter at issue in the contractor determination for the cost reporting period under appeal, and to make additional revisions on specific matters regardless of whether the contractor considered the matters in issuing the contractor determination. The Board's power to make additional revisions in a hearing decision does not authorize the Board to consider or decide a specific matter at issue for which it lacks jurisdiction (as described in § 405.1840(b) of this subpart) or which was not timely raised in the provider's hearing request. The Board's power under section 1878(d) of the Act and paragraph (a) of this section to make additional revisions is limited to those revisions necessary to resolve fully a specific matter at issue if—

(1) The Board has jurisdiction to grant a hearing on the specific matter at issue under section 1878(a) or (b) of the Act and § 405.1840 of this subpart; and

(2) The specific matter at issue was timely raised in an initial request for a Board hearing filed in accordance with § 405.1835 or § 405.1837 of this subpart, as applicable, or in a timely request to add issues to a single provider appeal submitted in accordance with § 405.1835(c) of this subpart.

(b)(1) If the Board has jurisdiction to conduct a hearing on a specific matter at issue solely under §§ 405.1840 and 405.1835 or § 405.1837 of this subpart, as applicable, and the legal authority to fully resolve the matter in a hearing decision (as described in §§ 405.1842(f), 405.1867, and 405.1871 of this subpart), the Board is authorized to do the following:

(i) Affirm, modify, or reverse the contractor's or Secretary's findings on each specific matter at issue in the contractor or Secretary determination under appeal.

(ii) Make additional revisions on each specific matter at issue regardless of whether the contractor considered these revisions in issuing the contractor determination under appeal, provided the Board does not consider or decide a specific matter for which it lacks jurisdiction (as described in § 405.1840(b) of this subpart) or that was not timely raised in the provider's hearing request.

(2) The Board's authority under this section to make the additional revisions is limited to those revisions necessary to resolve a specific matter at issue.

[73 FR 30261, May 23, 2008]
Notes of Decisions
Cited in 17 cases, 1979–2014 · leading case: V.N.A. Of Greater Tift County, Inc., a Georgia Non-Profit Corporation v. Margaret M. Heckler and Blue Cross and Blue Shi
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V.N.A. Of Greater Tift County, Inc., a Georgia Non-Profit Corporation v. Margaret M. Heckler and Blue Cross and Blue Shi (1983) ca11 “42 C.F.R. §§ 405.1869 , 405.373(a)(3); see generally 42 C.”
The Diplomat Lakewood Incorporated, an Ohio Corporation v. Patricia Roberts Harris, Secretary, U. S. Department of Healt (1979) cadc “42 C.F.R. § 405.1869 (1978). 13 *1017 Diplomat then took its case to the PRRB, where it was decided on a stipulated record.”
Hca Health Services of Oklahoma, Inc. v. Donna E. Shalala, Secretary, Department of Health and Human Services (1994) cadc “at § 1395oo (a). When reviewing an NPR, the Board may modify any matter covered by the provider’s cost report for the fiscal year at issue “even though such matter[] w[as] not considered by the intermediary in making such final determination.”
Visiting Nurse Ass'n of Brooklyn v. Thompson (2004) nyed “This court therefore finds that the PRRB acted within its delegated power to “affirm, modify or reverse a determination of an intermediary with respect to a cost report,” ( 42 C.F.R. § 405.1869 ) and affirms the Secretary’s final decision with respect to the Providers’…”
AllCare Home Health, Inc v. Shalala (2001) ca10 “Applicable regulations put AllCare on notice that the PRRB may raise issues sua sponte-Title 42 C.F.R. § 405.1869 states that the PRRB “shall have the power to affirm, modify, or reverse a determination of an intermediary with respect to a cost report and to make any other…”
Pamc, Ltd. v. Kathleen Sebelius (2014) ca9 “42 C.F.R. § 405.1869 (a); see also 42 U.S.”
St. Luke's Hospital v. Secretary of Health & Human Services (1986) mad “§ 1395oo(d); see also 42 C.F.R. § 405.1869 . The question whether this section gives the Board jurisdiction to hear appeals on reported but unclaimed costs has caused disagreement among the Circuit Courts of Appeals, and is a matter of first impression in this district.”
Rapid City Regional Hospital v. Sebelius (2010) dcd “Consistent with the authority and need to promulgate such rules, the Court cannot credit Plaintiffs suggestion that the Board may not dismiss the appeal for a procedural default because the regulations only allow it to “affirm, modify, or reverse a determination of an…”
Athens Community Hospital, Inc. v. Schweiker (1982) cadc · cites it 2× “§ 1395oo (d), 42 C.F.R. § 405.1869 , and Medicare Intermediary Manual § 2624.”
University of Cincinnati v. Shalala (1995) ohsd · cites it 5× “§ 1395oo (d); 42 C.F.R. § 405.1869 . The PRRB may also make any other modifications on matters covered by such cost report (including modifications adverse to the provider or other parties) even though such matters were not considered in the intermediary’s determination.”
Cambridge Hosp. Ass'n, Inc. v. Bowen (1986) mnd “42 C.F.R. § 405.1869 . 18 . In Cleveland Memorial the PRRB’s dismissal was based on a finding that the jurisdictional dollar amount requirements of section 1395oo(b) had not been satisfied.”
Borgess Medical Center v. Schweiker (1982) miwd “First, the PRRB is required by 42 C.F.R. § 405.1869 to comply with all laws and regulations which govern Medicare reimbursement.”
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