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 I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

42 C.F.R. § 405.974

Reconsideration and review of a contractor's dismissal of a request for redetermination

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(a) Reconsideration of a contractor determination. Except as provided in § 405.972, upon the basis of the evidence of record, the QIC must issue a reconsideration affirming or reversing, in whole or in part, the initial determination, including the redetermination, in question.

(b) Review of a contractor's dismissal of a redetermination request. (1) A party to a contractor's dismissal of a request for redetermination has a right to have the dismissal reviewed by a QIC, if the party files a written request for review of the dismissal with the QIC within 60 calendar days after receipt of the contractor's notice of dismissal.

(i) For purposes of this section, the date of receipt of the contractor's notice of dismissal is presumed to be 5 calendar days after the date of the notice of dismissal, unless there is evidence to the contrary.

(ii) For purposes of meeting the 60 calendar day filing deadline, the request is considered as filed on the date it is received by the QIC indicated on the notice of dismissal.

(2) If the QIC determines that the contractor's dismissal was in error, it vacates the dismissal and remands the case to the contractor for a redetermination.

(3) A QIC's review of a contractor's dismissal of a redetermination request is binding and not subject to further review.

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37703, June 30, 2005; 74 FR 65334, Dec. 9, 2009; 82 FR 5108, Jan. 17, 2017]
Notes of Decisions
Cited in 3 cases (1 in the last 5 years), 2010–2022 · leading case: Doctors Nursing & Rehab. Ctr. v. Sebelius, 613 F.3d 672 (7th Cir. 2010).
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Doctors Nursing & Rehab. Ctr. v. Sebelius, 613 F.3d 672 (7th Cir. 2010). “42 C.F.R. § 405.974 (b)(3). The regulation now states that the decision is "binding” — rather than “final” — "and not subject to any further review.”
First United Methodist Church v. Becerra (D. Neb. 2022). “Plaintiffs argue in their brief that they “have pled facts demonstrating the utter lack of process available to challenge re-opening decisions through an administrative appeal” but also make clear they “are not challenging application of 42 C.F.R. § 405.974 (b)(3), etc. based on…”
Doctors Nursing Rehab. v. Kathleen Sebelius (7th Cir. 2010). “42 C.F.R. § 405.974 (b)(3). The regulation now states that the decision is “binding”—rather than “final”—“and not subject to any further review.”
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