Source: https://www.hhs.gov/about/agencies/omha/the-appeals-process/legal-authorities/index.html
Timestamp: 2020-08-11 07:48:26
Document Index: 294962566

Matched Legal Cases: ['art 405', '§ 405', 'art 478', '§ 478', '§ 418', '§ 418', '§ 330', '§ 1852', '§ 1876', 'art 422', '§ 422', 'art 417', '§ 70', '§ 1860', 'art 423', '§ 423', '§ 418', '§ 418']

Legal Authorities | HHS.gov
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The current Medicare appeals process was established by various statutes and implementing regulations. The table below lists some of the statutes and regulations that govern the appeals process for Medicare claims and entitlement, Medicare Advantage organization determination, and Medicare prescription drug coverage determination appeals, as well as select OMHA and Centers for Medicare & Medicaid (CMS) program guidance.
Select Program Guidance
Medicare Part A and Part B fee-for-service claim, entitlement, and certain premium initial determinations
(42 U.S.C. 1395ff)
QIO Appeals Only
(42 U.S.C. 1320c-4)
42 C.F.R. part 405,
(§§ 405.1000–405.1063 for ALJ appeals)
42 C.F.R. part 478,
(§ 478.40 for ALJ appeals)
IRMAA Appeals Only
20 C.F.R. §§ 418.1301–418.1355
(§ 418.1350 for ALJ appeals) OMHA Case Processing Manual
(For prior versions, see the 2017 Case Processing Manual; Division II for Part A/B appeals, Division V for entitlement and certain premium appeals)
Medicare Claims Processing Manual, CMS Publ’n 100-04, Ch. 29
(§§ 330–330.6 for ALJ appeals)
Medicare Part C Medicare Advantage and competitive health plan organization determinations Social Security Act
§ 1852(g)
(42 U.S.C. 1395w-22(g))
§ 1876(c)(5)(B)
(42 U.S.C. 1395mm(c)(5)(B)) 42 C.F.R. part 422, subpart M
(§§ 422.600–405.612 for ALJ appeals)
42 C.F.R. part 417, subpart Q
(For prior versions, see the 2017 Case Processing Manual; Division III for Part C appeals)
(§§ 70–70.4.3 for ALJ appeals)
Medicare Part D plan sponsor coverage determinations and certain premium determinations Social Security Act
§ 1860D-4
(42 U.S.C. 1395w-104) 42 C.F.R. part 423,
subparts M and U
(§§ 423.1968–423.2063 for ALJ appeals)
20 C.F.R. §§ 418.2301–418.2355
(§ 418.2350 for ALJ appeals) OMHA Case Processing Manual
(For prior versions, see the 2017 Case Processing Manual; Division IV for Part D appeals)
*Statutory citations are given to the Social Security Act, as amended, with United States Code (U.S.C.) equivalents as parentheticals. However, please note that the online version of the U.S.C. may be more current than the online version of the Social Security Act.
The CMS Administrator also issues Rulings that serve as precedent final opinions and orders and statements of policy and interpretation. CMS Rulings are binding on all CMS components and OMHA adjudicators.
CMS Rulings issued in 1995 or later
​The Chair of the Departmental Appeals Board (DAB) may designate certain Medicare Appeals Council decisions as precedential. These precedential decisions are binding on all HHS components, including OMHA adjudicators.
With the exception of CMS Rulings, the legal authorities on this page address only the Medicare appeals process. Other statutes, regulations, and program guidance address Medicare coverage and payment rules. For general information about the items and services that Medicare covers, please visit the portion of the Medicare.gov website entitled What Medicare Covers. For general information about Part C Medicare Advantage plans, visit this page. For general information about Part D prescription drug plans, visit this page.
Content last reviewed on March 1, 2019