42 C.F.R. § 422.560

Basis and scope

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(a) Statutory basis. (1) Section 1852(f) of the Act provides that an MA organization must establish meaningful grievance procedures.

(2) Section 1852(g) of the Act establishes requirements that an MA organization must meet concerning organization determinations and appeals.

(3) Section 1869 of the Act specifies the amount in controversy needed to pursue a hearing and judicial review and authorizes representatives to act on behalf of individuals that seek appeals. These provisions are incorporated for MA appeals by section 1852(g)(5) of the Act and part 405 of this chapter.

(4) Section 1859(f)(8) of the Act provides for, to the extent feasible, unifying grievances and appeals procedures under sections 1852(f), 1852(g), 1902(a)(3), 1902(a)(5), and 1932(b)(4) of the Act for Medicare and Medicaid covered items and services provided by specialized MA plans for special needs individuals described in subsection 1859(b)(6)(B)(ii) of the Act for individuals who are eligible under titles XVIII and XIX of the Act. Beginning January 1, 2021, procedures established under section 1859(f)(8) of the Act apply in place of otherwise applicable grievances and appeals procedures with respect to Medicare and Medicaid covered items and services provided by applicable integrated plans.

(b) Scope. This subpart sets forth—

(1) Requirements for MA organizations with respect to grievance procedures, organization determinations, and appeal procedures.

(2) The rights of MA enrollees with respect to organization determinations, and grievance and appeal procedures.

(3) The rules concerning notice of noncoverage of inpatient hospital care.

(4) The rules that apply when an MA enrollee requests immediate QIO review of a determination that he or she no longer needs inpatient hospital care.

(5) Requirements for applicable integrated plans with respect to procedures for integrated grievances, integrated organization determinations, and integrated reconsiderations.

(c) Relation to ERISA requirements. Consistent with section 1857(i)(2) of the Act, provisions of this subpart may, to the extent applicable under regulations adopted by the Secretary of Labor, apply to claims for benefits under group health plans subject to the Employee Retirement Income Security Act.

[63 FR 35107, June 26, 1998, as amended at 70 FR 4738, Jan. 28, 2005; 84 FR 15833, Apr. 16, 2019]

Notes of Decisions

Cited in 11 cases (3 in the last 5 years), 2001–2025 · leading case: Giesse v. Secretary of the Department of Health & Human Services

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Giesse v. Secretary of the Department of Health & Human Services (2008) ca6 · cites it 4× “§ 1395w-22(g); 42 C.F.R. § 422.560 . Aside from this administrative review process, the Medicare Act bars judicial review of claims that “arise under” the Act.”

Lifecare Hospitals, Inc. v. Ochsner Health Plan, Inc. (2001) lawd · cites it 2× “The administrative remedy procedure for a Medicare participant enrolled in a “Medicare + Choice” plan, such as the OHP plan, is delineated at 42 C.F.R. § 422.560 et seq. Under section 422.”

Harris v. Pacificare Life & Health Ins. Co. (2007) almd “, 42 C.F.R. §§ 422.560 — 422.612, a point upon which the court expresses no opinion — replicate in any measure the comprehensive civil enforcement schemes and jurisdictional provisions of ERISA § 502(a) and LMRA § 301.”

Yarick v. PacifiCare of California (2009) calctapp “504(a) (2008)), and an administrative grievance procedure that allows the patient to challenge a determination that a service is not covered by the plan or is not medically necessary ( 42 C.F.R. § 422.560 et seq. (2008)). CMS periodically reviews all contracts and usage data,…”

United Behavioral Health v. Maricopa Integrated Health System (2015) arizctapp “42 C.F.R. §§ 422.560 -.626. ¶ 22 Under Medicare’s administrative review procedure, “[j]udicial review of a claim for benefits is available only after the Secretary [of HHS] has rendered a ‘final decision’ on the claim,” and a “final decision by the Secretary on a claim ‘arising…”

Giesse v. Secretary of the Department of Health & Human Services (2006) ohnd “” See 42 C.F. R. § 422.560 et seq. An “organization determination” is: [A]ny determination made by an MA organization with respect to any of the following: (1) Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or…”

Dial v. Healthspring of Alabama, Inc. (2007) alsd “See 42 C.F.R. § 422.560 , et seq. Also, as an introductory matter, the regulations explain that the scope of Part 422 “establishes standards and sets forth the requirements, limitations, and procedures for Medicare services furnished, or paid for, by Medicare Advantage…”

Zhang v. UnitedHealthCare (2022) azd “See 42 C.F.R. § 422.560 27 et seq. (Grievances, Organization Determinations and Appeals for the Medicare Advantage 28 Program).”

Global Rescue Jets LLC v. Kaiser Foundation Health Plan, Inc. (2020) casd “26 The administrative review process for grievances under an MA plan is outlined in 27 42 CFR § 422.560 et seq. (Grievances, Organization Determinations and Appeals for the 28 Medicare Advantage Program).”

Minimally Invasive Surgery Hospital, Inc. v. United HealthCare Services, Inc. (2025) ksd “As a general matter, a Medicare Advantage organization must have a procedure in place to initially determine (1) if an enrollee in a Medicare plan will receive a health service, and (2) the amount an enrollee is required to pay for a service under the plan.”

Hospital Quirurgica Del Sur v. Martin's Point Health Care, Inc. (2025) ca1 “§ 1395w-22(g); 42 C.F.R. §§ 422.560 - 422.634 (2025). The "final decision" of the agency is reviewable in federal district court, subject to the satisfaction of an amount-in-controversy requirement.”

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