CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER B—MEDICARE PROGRAM (parts 405 to 426) > PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT > SUBPART E—Limitations on Payment for Services Covered Under Group Health Plans: General Provisions (§411.100 to §411.130) > 411.124—Administrator's review of hearing decision.

411.124—Administrator's review of hearing decision.

(a) Request for review. A party's request for review of a hearing officer's decision must be in writing (not in facsimile or other electronic medium) and must be received by the Administrator within 25 days from the date on the decision.
(b) Office of the Attorney Advisor responsibility. The Office of the Attorney Advisor examines the hearing officer's decision, the requests made by any of the parties or CMS, and any submission made in accordance with the provisions of this section in order to assist the Administrator in deciding whether to review the decision.
(c) Administrator's discretion. The Administrator may—
(1) Review or decline to review the hearing officer's decision;
(2) Exercise this discretion on his or her own motion or in response to a request from any of the parties; and
(3) Delegate review responsibility to the Deputy Administrator. (As used in this section, the term “Administrator” includes “Deputy Administrator” if review responsibility has been delegated.)
(d) Basis for decision to review. In deciding whether to review a hearing officer's decision, the Administrator considers—
(1) Whether the decision—
(i) Is based on a correct interpretation of law, regulation, or CMS Ruling;
(ii) Is supported by substantial evidence;
(iii) Presents a significant policy issue having a basis in law and regulations;
(iv) Requires clarification, amplification, or an alternative legal basis for the decision; and
(v) Is within the authority provided by statute, regulation, or CMS Ruling; and
(2) Whether review may lead to the issuance of a CMS Ruling or other directive needed to clarify a statute or regulation.
(e) Notice of decision to review or not to review. (1) The Administrator gives all parties prompt written notice of his or her decision to review or not to review.
(2) The notice of a decision to review identifies the specific issues the Administrator will consider.
(f) Response to notice of decision to review. (1) Within 20 days from the date on a notice of the Administrator's decision to review a hearing officer's decision, any of the parties may file with the Administrator any or all of the following:
(i) Proposed findings and conclusions.
(ii) Supporting views or exceptions to the hearing officer's decision.
(iii) Supporting reasons for the proposed findings and exceptions.
(iv) A rebuttal to another party's request for review or to other submissions already filed with the Administrator.
(2) The submissions must be limited to the issues the Administrator has decided to review and confined to the record established by the hearing officer.
(3) All communications from the parties concerning a hearing officer's decision being reviewed by the Administrator must be in writing (not in facsimile or other electronic medium) and must include a certification that copies have been sent to all other parties.
(4) The Administrator does not consider any communication that does not meet the requirements of this paragraph.
(g) Administrator's review decision. (1) The Administrator bases his or her decision on the following:
(i) The entire record developed by the hearing officer.
(ii) Any materials submitted in connection with the hearing or under paragraph (f) of this section.
(iii) Generally known facts not subject to reasonable dispute.
(2) The Administrator mails copies of the review decision to all parties within 120 days from the date of the hearing officer's decision.
(3) The Administrator's review decision may affirm, reverse, or modify the hearing decision or may remand the case to the hearing officer.
(h) Basis and effect of remand— (1) Basis. The bases for remand do not include the following:
(i) Evidence that existed at the time of the hearing and that was known or could reasonably have been expected to be known.
(ii) A court case that was either not available at the time of the hearing or was decided after the hearing.
(iii) Change of the parties' representation.
(iv) An alternative legal basis for an issue in dispute.
(2) Effect of remand. (i) The Administrator may instruct the hearing officer to take further action with respect to the development of additional facts or new issues or to consider the applicability of laws or regulations other than those considered during the hearing.
(ii) The hearing officer takes the action in accordance with the Administrator's instructions in the remand notice and again issues a decision.
(iii) The Administrator may review or decline to review the hearing officer's remand decision in accordance with the procedures set forth in this section.
(i) Finality of decision. The Administrator's review decision, or the hearing officer's decision following remand, is the final Departmental decision and is binding on all parties unless the Administrator chooses to review the decision in accordance with this section, or the decision is reopened in accordance with § 411.126.