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 C—Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans

42 C.F.R. § 405.375

Time limits for, and notification of, administrative determination after receipt of rebuttal statement

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

(a) Submission and disposition of evidence. If the provider or supplier submits a statement, under § 405.374, as to why a suspension of payment, offset, or recoupment should not be put into effect, or, under § 405.372(b)(2), why a suspension should be terminated, CMS, the intermediary, or carrier must within 15 days, from the date the statement is received, consider the statement (including any pertinent evidence submitted), together with any other material bearing upon the case, and determine whether the facts justify the suspension, offset, or recoupment or, if already initiated, justify the termination of the suspension, offset, or recoupment. Suspension, offset, or recoupment is not delayed beyond the date stated in the notice in order to review the statement.

(b) Notification of determination. The Medicare contractor must send written notice of the determination made under paragraph (a) of this section to the provider or supplier. The notice must—

(1) In the case of offset or recoupment, contain rationale for the determination; and

(2) In the case of suspension of payment, contain specific findings on the conditions upon which the suspension is initiated, continued, or removed and an explanatory statement of the determination.

(c) Determination is not appealable. A determination made under paragraph (a) of this section is not an initial determination and is not appealable.

[61 FR 63747, Dec. 2, 1996]
Notes of Decisions
Cited in 13 cases (2 in the last 5 years), 1998–2025 · leading case: D&G Holdings, LLC v. Sylvia Mathews Burwell
Sort: Relevance Newest Treatment
D&G Holdings, LLC v. Sylvia Mathews Burwell (2016) lawd · cites it 3× “42 C.F.R. § 405.375 (c). After an initial determination is made on the merits by a CMS contractor, the provider may appeal that determination, but must weather the Medicare appeals process.”
True Health Diagnostics, LLC v. Azar (2019) txed · cites it 2× “" 42 C.F.R. § 405.375 (b)(2). This determination is not appealable and "is not an initial determination" within the Medicare Act administrative process.”
Long Island Ambulance, Inc. v. Thompson (2002) nyed · cites it 4× “42 C.F.R. § 405.375 (a). The carrier then must send written notice of its determination to the provider.”
True Health Diagnostics, LLC v. Azar (2019) txed · cites it 2× “" 42 C.F.R. § 405.375 (b)(2). This determination is not appealable and "is not an initial determination" within the Medicare Act administrative process.”
Total Renal Laboratories, Inc. v. Shalala (1999) gand “42 C.F.R. § 405.375 . On October 1, 1998, shortly before the first suspension was due to expire, the carrier reopened and redetermined plaintiffs claims for the period January 1, 1995 through April 30,1996 (Defendant’s Exhibit 2).”
Midwest Family Clinic, Inc. v. Shalala (1998) mied “' 42 C.F.R. § 405.375 (a). The decision to suspend benefits is not a final determination under 42 U.”
Naushad, M.D. P.C. v. United States Department of Health and Human Services (2020) moed · cites it 5× “On January 6, 2020, APC filed the instant petition requesting this Court grant mandamus relief by ordering Respondent’s prompt compliance, through its agent CMS, with CMS’ obligation pursuant to 42 C.F.R. § 405.375 to “determine whether the facts justify the suspension, offset,…”
Maka Hospice, Inc. v. Alex M. Azar, II (2020) cacd · cites it 2× “42 C.F.R. § 405.375 (c); cf. 42 C.F.R. 20 § 405.”
Simply Home Healthcare v. AdvanceMed Corporation (2021) ca7 “Nor does the fact that AdvanceMed’s decision, after reviewing plaintiff’s rebuttal, to continue suspending plaintiff’s payments while it investigated was “not appealable,” 42 C.F.R. § 405.375 (c), exempt plaintiff from obtaining a final decision.”
Simply Home Healthcare, LLC v. AdvanceMed Corporation (2020) ilnd “22) Simply Home interprets 42 C.F.R. § 405.375 (c) to mean the complete “nonexistence of administrative remedies.”
PainMD, LLC v. Azar (2019) tnmd “See 42 C.F.R. § 405.375 (c); MedPro Health Providers, LLC v.”
Acute Care Ambulance Service, LLC v. Alex M. Azar II (2020) txsd “ntinue the Medicare payment suspension every 180 days, and “[g]ood cause not to continue to suspend payments to an individual or entity against which there are credible allegations of fraud must be deemed to exist if a payment suspension has been in effect for 18 months and…”
Show all 13 citing cases →
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.