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. § 422.612

Judicial review

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(a) Review of ALJ's or attorney adjudicator's decision. Any party, including the MA organization, may request judicial review (upon notifying the other parties) of an ALJ's or attorney adjudicator's decision if—

(1) The Council denied the party's request for review; and

(2) The amount in controversy meets the threshold requirement established annually by the Secretary.

(b) Review of Council decision. Any party, including the MA organization, may request judicial review (upon notifying the other parties) of the Council decision if it is the final decision of CMS and the amount in controversy meets the threshold established in paragraph (a)(2) of this section.

(c) How to request judicial review. In order to request judicial review, a party must file a civil action in a district court of the United States in accordance with section 205(g) of the Act. See part 405 of this chapter for a description of the procedures to follow in requesting judicial review.

[63 FR 35107, June 26, 1998; 63 FR 52614, Oct. 1, 1998, as amended at 65 FR 40331, June 29, 2000; 70 FR 4740, Jan. 28, 2005; 82 FR 5125, Jan. 17, 2017]
Notes of Decisions
Cited in 17 cases (7 in the last 5 years), 2005–2026 · 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 2× “…if the MAC declines to review the ALJ’s decision. 42 U.S.C. § 1395w-22(g)(5); 42 C.F.R. § 422.612 . The Medicare Act’s grant of subject matter jurisdiction only permits judicial review of “the final decision of [the Secretary] made after a hearing.” 42 U.S.C. § 405</”
Global Rescue Jets, LLC v. Kaiser Foundation Health Plan (2022) ca9 “…is $1,000 or more (adjusted for inflation). 42 U.S.C. § 1395w-22(g)(5); 42 C.F.R. § 422.612 . 3 The statutory provision establishing this review scheme, 42 U.S.C. § 1395w-22(g), tracks the language of the 3 The regulations state that a provider may pursue these…”
American Chiropractic Ass'n v. Leavitt (2005) cadc “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 (a), (c). The chiropractor who provided the service could also mount an administrative challenge by “waivfing] any right to payment from the enrollee” and becoming the enrollee’s assignee.”
Naomi Aylward v. Selecthealth, Inc. (2022) ca9 “§ 1395w- 22(g)(5); 42 C.F.R. § 422.612 .”
Associates Rehabilitation Recovery, Inc. v. Humana Medical Plan, Inc. (2014) flsd “42 C.F.R. § 422.612 (a) (2014). As the Court finds that dismissal without prejudice is appropriate in order to allow Plaintiff -to pursue its administrative remedies, the Court declines to address Defendant’s alternative arguments that dismissal is appropriate because Plaintiffs…”
Haaland v. Presbyterian Health Plan, Inc. (2018) nmd “…index="77" url="https://cite.case.law/citations/?q=42%20C.F.R.%20%C2%A7%20422.612"> 42 C.F.R. § 422.612 (a) (2014) ). Here, Plaintiffs insist that they are not complaining about the denial of Medicare benefits but are, rather, seeking damages "due to PHP's medical…”
Doctors Medical Center of Modesto, Inc. v. Kaiser Foundation Health Plan, Inc. (2013) caed “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 (c). With respect to its remaining state common law claims for open book account and account stated, the Hospital argues that those claims do not “arise under” the Medicare Act and are therefore not subject to its exhaustion requirements.”
Rapport v. Leavitt (2008) nywd “§ 1395ff (b)(1)(E), 42 C.F.R. § 422.612 (a) and (b)). BACKGROUND On December 5, 2006, plaintiff, then ninety (90) years old, was admitted to Highland Hospital (“Highland”) in Rochester, N.”
Tenet Healthsystem GB, Inc. v. Care Improvement Plus South Central Insurance (2016) gand “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 (c). The Eleventh Circuit has recognized that a lawsuit that seeks to recover on any claim “arising under” the Medicare Act must first be brought through the HHS administrative appeals process before it can be taken to federal court.”
Giesse v. Secretary of the Department of Health & Human Services (2006) ohnd “§ 1395w-22(g)(5); 42 C.F.R. § 422.612 . The Secretary has adopted an administrative review process that distinguishes between “grievances” and challenges to an “organization determination.”
Naomi Aylward v. Selecthealth, Inc. (2022) ca9 “§ 1395w- 22(g)(5); 42 C.F.R. § 422.612 .”
John Kodenkandeth v. UPMC Health Plan Inc (2026) ca3 · cites it 3× “562 (b), an enrollee may seek judicial review “in a district court of the United States” if “[t]he amount in controversy meets the threshold requirement,” 42 C.F.R. § 422.612 ; 42 U.”
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