42 C.F.R. § 422.574
Parties to the organization determination
The parties to the organization determination are—
(a) The enrollee (including his or her representative);
(b) An assignee of the enrollee (that is, a physician or other provider who has furnished a service to the enrollee and formally agrees to waive any right to payment from the enrollee for that service);
(c) The legal representative of a deceased enrollee's estate; or
(d) Any other provider or entity (other than the MA organization) determined to have an appealable interest in the proceeding.
Notes of Decisions
Cited in 14
cases (2 in the last 5 years), 2000–2025 · leading case: Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Company
Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Company (2017)
“s estate,” or “[a]ny other provider or entity (other than the MA organization) determined to have an appealable interest in the proceeding ” 42 C.F.R. § 422.574 . If any one of the foregoing parties .”
Christus Health Gulf Coast v. Aetna, Inc. (2005)
“See 42 C.F.R. §§ 422.574 (b), (d), 422.578-.626 (2003).”
Rencare, Ltd. v. Humana Health Plan of Texas, Inc., Doing Business as Humana Health Plan of San Antonio Humana Hmo of Te (2005)
“Humana argues that RenCare is acting as an assignee of Humana’s M + C beneficiaries and thus may be a party to an organization determination under 42 C.F.R. § 422.574 (b), which allows providers to be parties to an organization determination as assignees of beneficiaries.”
American Chiropractic Ass'n v. Leavitt (2005)
“42 C.F.R. § 422.574 (b). There are minimum amounts in controversy — $100 for a hearing before an administrative law judge, $1000 for judicial review, see 42 U.”
American Chiropractic Ass'n, Inc. v. Shalala (2001)
“First, the Secretary contends that a chiropractor may become a party to an organization determination by becoming the authorized representative of a Medicare enrollee under 42 C.F.R. §§ 422.574 (a), 404.1705(b). See Def.”
Caris MPI v. UnitedHealthcare (2024)
“Specifically, United asserts that Caris is an “assignee” of enrollee claims, as defined by 42 C.F.R. § 422.574 (b). According to United, “it doesn’t matter” whether an enrollee actually assigned his or her claim to Caris because an assignee includes any “provider who has…”
Puerto Rican Ass'n of Physical Medicine & Rehabilitation, Inc. v. United States (2008)
“42 C.F.R. § 422.574 (b). Among the medical costs covered by Medicare are those for services “furnished as an incident to a physician’s professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included…”
United Behavioral Health v. Maricopa Integrated Health System (2016)
“562(e)(2) applies to extinguish a contract provider’s administrative appeal rights, the provision would conflict with regulations making a contract provider a party to an organization determination with full appeal rights when that provider has waived the right to payment from…”
American Chiropractic Ass'n v. Shalala (2000)
“See 42 C.F.R. §§ 422.574 , 422.582. An organization determination is a determination by a managed care organization regarding payment for emergency services, payment for other health services believed to be covered by Medicare, or discontinuation of a health service.”
Christus Health Gulf Coast, Christus Health Southeast Texas, Gulf Coast Division, Inc., Memorial Hermann Hospital System (2005)
“See 42 C.F.R. §§ 422.574 (b), (d), 422.578–.626 (2003).”
United Behavioral Health v. Maricopa Integrated Health System (2016)
“See 42 C.F.R. §§ 422.574 (b), .578—.626; see also Nitro-Lift Techs.”
Hospital Quirurgica Del Sur v. Martin's Point Health Care, Inc. (2025)
“urt, 6 Medicare Part C regulations define the parties to an organization determination as follows: (a) The enrollee (including his or her representative); (b) An assignee of the enrollee (that is, a physician or other provider who has furnished a service to the enrollee and…”
— 42 C.F.R. § 422.574(b) — 1 case
United Behavioral Health v. Maricopa Integrated Health System (2016)
“562(e)(2) applies to extinguish a contract provider’s administrative appeal rights, the provision would conflict with regulations making a contract provider a party to an organization determination with full appeal rights when that provider has waived the right to payment from…”
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