Source: http://www.law.cornell.edu/cfr/text/42/460.122
Timestamp: 2014-09-23 07:09:25
Document Index: 101841222

Matched Legal Cases: ['art 460', '§ 460', '§ 460', '§ 1302', '§ 1395', 'arts 403', 'arts 403', 'arts 403']

42 CFR 460.122 - PACE organization's appeals process. | LII / Legal Information Institute
CFR › Title 42 › Chapter IV › Subchapter E › Part 460 › Subpart G › Section 460.122 42 CFR 460.122 - PACE organization's appeals process.
§ 460.122
PACE organization's appeals process.
For purposes of this section, an appeal is a participant's action taken with respect to the PACE organization's noncoverage of, or nonpayment for, a service including denials, reductions, or termination of services.
PACE organization's written appeals process.
The PACE organization must have a formal written appeals process, with specified timeframes for response, to address noncoverage or nonpayment of a service.
Notification of participants.
Upon enrollment, at least annually thereafter, and whenever the interdisciplinary team denies a request for services or payment, the PACE organization must give a participant written information on the appeals process.
At a minimum, the PACE organization's appeals process must include written procedures for the following:
Timely preparation and processing of a written denial of coverage or payment as provided in § 460.104(c)(3).
How a participant files an appeal.
Documentation of a participant's appeal.
Appointment of an appropriately credentialed and impartial third party who was not involved in the original action and who does not have a stake in the outcome of the appeal to review the participant's appeal.
Responses to, and resolution of, appeals as expeditiously as the participant's health condition requires, but no later than 30 calendar days after the organization receives an appeal.
Maintenance of confidentiality of appeals.
A PACE organization must give all parties involved in the appeal the following:
Appropriate written notification.
A reasonable opportunity to present evidence related to the dispute, in person, as well as in writing.
Services furnished during appeals process.
During the appeals process, the PACE organization must meet the following requirements:
For a Medicaid participant, continue to furnish the disputed services until issuance of the final determination if the following conditions are met:
The PACE organization is proposing to terminate or reduce services currently being furnished to the participant.
The participant requests continuation with the understanding that he or she may be liable for the costs of the contested services if the determination is not made in his or her favor.
Continue to furnish to the participant all other required services, as specified in subpart F of this part.
Expedited appeals process.
A PACE organization must have an expedited appeals process for situations in which the participant believes that his or her life, health, or ability to regain or maintain maximum function could be seriously jeopardized, absent provision of the service in dispute.
Except as provided in paragraph (f)(3) of this section, the PACE organization must respond to the appeal as expeditiously as the participant's health condition requires, but no later than 72 hours after it receives the appeal.
The PACE organization may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons:
The participant requests the extension.
The organization justifies to the State administering agency the need for additional information and how the delay is in the interest of the participant.
Determination in favor of participant. A PACE organization must furnish the disputed service as expeditiously as the participant's health condition requires if a determination is made in favor of the participant on appeal.
Determination adverse to participant. For a determination that is wholly or partially adverse to a participant, at the same time the decision is made, the PACE organization must notify the following:
The State administering agency.
Analyzing appeals information.
A PACE organization must maintain, aggregate, and analyze information on appeal proceedings and use this information in the organization's internal quality assessment and performance improvement program.
[64 FR 66279, Nov. 24, 1999, as amended at 71 FR 71336, Dec. 8, 2006]
This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.United States CodeU.S. Code: Title 42 - THE PUBLIC HEALTH AND WELFARE§ 1302 - Rules and regulations; impact analyses of Medicare and Medicaid rules and regulations on small rural hospitals§ 1395 - Prohibition against any Federal interference
Title 42 published on 2013-10-01The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR 460 after this date.2014-04-16; vol. 79 # 73 - Wednesday, April 16, 201479 FR 21552 - Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities
typeregulations.gov FR Doc.2014-08602 RIN0938-AR72 CMS-3277-P DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services Proposed rule. To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 16, 2014. 42 CFR Parts 403, 416, 418, 460, 482, 483, and 485 SummaryThis proposed rule would amend the fire safety standards for Medicare and Medicaid participating hospitals, critical access hospitals (CAHs), long-term care facilities, intermediate care facilities for individuals with intellectual disabilities (ICF-IID), ambulatory surgery centers (ASCs), hospices which provide inpatient services, religious non-medical health care institutions (RNHCIs), and programs of all-inclusive care for the elderly (PACE) facilities. Further, this proposed rule would adopt the 2012 edition of the Life Safety Code (LSC) and eliminate references in our regulations to all earlier editions. It would also adopt the 2012 edition of the Health Care Facilities Code, with some exceptions. We are providing the LSC citation, a description of the 2012 requirement, and an explanation of its benefits for health care facilities, patients, staff, and visitors over the 2000 version in each occupancy section.
2014-02-21; vol. 79 # 35 - Friday, February 21, 201479 FR 9872 - Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers; Extension of Comment Period
typeregulations.gov FR Doc.2014-03710 RIN CMS-3178-N DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services Proposed rule; extension of the comment period. The comment period for the proposed rule published in the December 27, 2013 Federal Register (78 FR 79082 through 79200) is extended to March 31, 2014. 42 CFR Parts 403, 416, 418, 441, 460, 482, 483, 484, 485, 486, 491, and 494 SummaryThis document extends the comment period for the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers proposed rule, which was published in the December 27, 2013 Federal Register (78 FR 79082 through 79200). The comment period for the proposed rule, which would have ended on February 25, 2014, is extended to March 31, 2014.
2013-12-27; vol. 78 # 249 - Friday, December 27, 201378 FR 79082 - Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
typeregulations.gov FR Doc.2013-30724 RIN0938-AO91 CMS-3178-P DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services Proposed rule. To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on February 25, 2014. 42 CFR Parts 403, 416, 418, 441, 460, 482, 483, 484, 485, 486, 491, and 494 SummaryThis proposed rule would establish national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to ensure that they adequately plan for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It would also ensure that these providers and suppliers are adequately prepared to meet the needs of patients, residents, clients, and participants during disasters and emergency situations. We are proposing emergency preparedness requirements that 17 provider and supplier types must meet to participate in the Medicare and Medicaid programs. Since existing Medicare and Medicaid requirements vary across the types of providers and suppliers, we are also proposing variations in these requirements. These variations are based on existing statutory and regulatory policies and differing needs of each provider or supplier type and the individuals to whom they provide health care services. Despite these variations, our proposed regulations would provide generally consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.