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DAB Medicare Appeals Council Regulations
The DAB Medicare Appeals
Council (MAC) currently operates under regulations issued by
both the Department of Health and Human Services (HHS) and
the Social Security Administration (SSA). These regulations
may be found in the Code of Federal Regulations (CFR).
With a few exceptions, appeals
to the MAC are governed by procedures at 20 CFR 404.967
(20 CFR 404) et seq., that were published by SSA
when it handled appeals under both the Social Security and
Medicare Programs. These procedures are incorporated in the
HHS Medicare regulations governing the following
appeals:
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Medicare Part
A
Claims: Appeals of Administrative Law Judge (ALJ)
decisions and dismissals filed by beneficiaries, providers
of services and subrogees (such as Medicaid State
agencies) concerning Part A fee-for-service claims.
See 42 CFR 405.701 - 405.753
(42 CFR 405).
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Medicare Part
B
Claims: Appeals of ALJ decisions and dismissals
brought by beneficiaries, providers, suppliers, and
subrogees concerning Part B fee-for-service claims. See 42 CFR 405.801- 405.877
(42 CFR 405).
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Determinations by
Managed Care Organizations: Appeals of ALJ
decisions and dismissals concerning determinations made by
health maintenance organizations and competitive medical
plans governed by section 1876 of the Social Security Act,
42 USC 1395w-27, and 42 CFR part 417. These cases involve
beneficiary requests for services or for reimbursement for
services obtained "out of plan." See 42 CFR 417.600-
405.638.
(42 CFR 417)
(42 CFR 405).
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Determinations by
Health Care Prepayment Plans: Appeals of ALJ
decisions and dismissals concerning determinations made by
health care prepayment plans (HCPPs).See 42 CFR 417.830-417.840.
(42 CFR 417)
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Determinations by
Medicare+Choice Organizations: Appeals of ALJ
decisions and dismissals concerning determinations made by
Medicare+Choice organizations. The Medicare+Choice Program
was established in 1997 and is governed by regulations
which may be found at 42 CFR part 422. These cases involve
beneficiary requests for services or for reimbursement for
services obtained "out of plan." See 42 CFR
422.560-422.622.
(42 CFR 422)
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Determinations by
Peer Review Organizations (PRO): Appeals of ALJ
decisions and dismissals brought by beneficiaries
concerning PRO determinations made under section 1154 of
the Social Security Act, 42 USC 1320c-3. These cases
involve determinations that services furnished or proposed
to be furnished to a beneficiary are not reasonable and
necessary, or not delivered in the most appropriate
setting. See 42 CFR 476.1 - 478.48
(42 CFR 476)
(42 CFR 478). Also, while providers of services may
not appeal the medical necessity aspect of a PRO
determination beyond the reconsideration level, they may
appeal a PRO's "limitation of liability" determination to
an ALJ and the MAC under regulations codified at 42
CFR 404, subparts G and H. See 42 CFR 478.14(c)(2).
(42 CFR 478)
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Procedural
Regulations
Governing Review by the Medicare Appeals
Council: Regulations beginning at 20 CFR 404.967
(20 CFR 404) regarding review by the SSA
Appeals Council are applicable to review of Medicare
appeals by the DAB Medicare Appeals Council.
Also, 20 CFR part 404
(20 CFR 404), subpart J (Determinations,
Administrative Review Process, and Reopening of Determinations
and Decisions) and subpart R (Representation of Parties) are
applicable to Medicare appeals, except to the extent that
specific provisions are contained in Medicare regulations.
***These regulations
may be accessed through the designated Government Printing
Office (GPO) links.
Medicare Operations
Division/Medicare Appeals Council DAB Medicare Appeals Council Frequently
Asked Questions
Last revised: October 4, 2002
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