Title 42
SECTION 422.2615
422.2615 Review by the Administrator.
§ 422.2615 Review by the Administrator.(a) Request for review by Administrator. If an MA organization is dissatisfied with the hearing official's decision, it may request that the CMS Administrator review the decision.
(1) The request must be filed with the CMS Administrator within 30 calendar days of the date of the hearing official's decision.
(2) The request must provide evidence or reasons to substantiate the request.
(b) Content of request. The MA organization must submit with its request all supporting documentation, evidence, and substantiation that it wants to be considered.
(1) Documentation, evidence, or substantiation submitted after the filing of the request will not be considered.
(2) Neither the MA organization, nor CMS may submit new evidence.
(c) Discretionary review. After receiving a request for review, the CMS Administrator has the discretion to review the hearing official's decision in accordance with paragraph (e) of this section or to decline to review said decision.
(d) Notification of decision whether to review. The Administrator notifies the MA organization within 45 days of receiving the MA organization's hearing request of whether he or she intends to review the hearing official's decision.
(1) If the Administrator agrees to review the hearing official's decision, CMS may file a rebuttal statement within 30 days of the Administrator's notice to the plan that the request for review has been accepted. CMS sends its rebuttal statement to the plan at the same time it is submitted to the Administrator.
(2) If the CMS Administrator declines to review the hearing official's decision, the hearing official's decision is final and binding.
(e) CMS Administrator's review. If the CMS Administrator agrees to review the hearing official's decision, he or she determines, based upon this decision, the hearing record, and any arguments submitted by the MA organization or CMS in accordance with this section, whether the determination should be upheld, reversed, or modified. The Administrator furnishes a written decision, which is final and binding, to the MA organization and to CMS.