C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 422—MEDICARE ADVANTAGE PROGRAM › Subpart M—Grievances, Organization Determinations and Appeals

42 C.F.R. § 422.576

Effect of an organization determination

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The organization determination is binding on all parties unless it is reconsidered under §§ 422.578 through 422.596 or is reopened and revised under § 422.616.

Notes of Decisions
Cited in 7 cases (1 in the last 5 years), 2006–2022 · leading case: Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016).
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Humana Med. Plan, Inc. v. W. Heritage Ins. Co., 832 F.3d 1229 (11th Cir. 2016). · cites it 2× “See 42 C.F.R. § 422.576 . Even if Western retains the right to dispute the amount, its argument regarding Ms.”
Global Rescue Jets, LLC v. Kaiser Found. Health Plan, 30 F.4th 905 (9th Cir. 2022). “See 42 C.F.R. § 422.576 . Excusing exhaustion of administrative remedies would interfere with the agency’s opportunity to review those claims.”
Haaland v. Presbyterian Health Plan, Inc., 292 F. Supp. 3d 1222 (D.N.M. 2018). · cites it 2× “§ 405 (g) - (h) ; 42 C.F.R. § 422.576 . This administrative channeling requirement serves important governmental interests in administrative efficiency and judicial economy, and it protects administrative agency authority, giving agencies an opportunity to correct their own…”
Humana Med. Plan, Inc. v. Reale, 180 So. 3d 195 (Fla. 3d DCA 2015). · cites it 2× “23 42 C.F.R. § 422.576 (2009). 34 (the “MSP Act”),24 and reimbursement under Mrs.”
Matthews v. Leavitt, 452 F.3d 145 (2d Cir. 2006). “612 (1998) (repealed) (organization determinations binding unless reconsideration sought); 42 C.F.R. § 422.576 (2006) (currently applicable analogous provision); see also 42 C.”
Honey v. Bayhealth Med. Ctr., Inc. (Del. Super. Ct. 2015). “23 Reed, supra at *7 (citing 42 C.F.R. § 422.576 (organizational determination); 42 C.”
Humana Med. Plan, Inc. v. Reale (Fla. 3d DCA 2015). “Reale’s Gold Plus HMO plan as 23 42 C.F.R. § 422.576 (2009). 24 42 U.S.C. § 1395y(b) (2009), discussed in detail below.”
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