CMS Regulations & Guidance- About CMS Hearing Officer
Guidance for information regarding CMS Hearing Officer.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 15, 2020
The CMS Hearing Officer adjudicates a diverse range of matters brought by healthcare institutions, insurance issuers, state Medicaid agencies, organ procurement organizations, and other entities under various statutory and regulatory authorities for which the Office of Hearings ("OH") serves as Reviewing Official, Reconsideration Official, or Presiding Officer.
Appeal Types & Subtypes
Accountable Care Organization Shared Losses
Affordable Care Act ("ACA") Financial Appeals
Cost Plan Reimbursement (e.g., Cost HMO) Appeals
Group Health Plan Non-Conformance Appeals
Health Maintenance Organization Competitive Medical Plan ("HMO-CMP") Appeals
- Contract Denial;
- Contract Non-Renewal;
- Contract Termination; and
- Intermediate Sanctions
Medicaid State Plan Appeals
- State Plan Amendment Disapproval; and
- Compliance Determination
Medicare Administrative Contractor Termination Appeals
Medicare Advantage/Prescription Drug Plan ("MA/PD") Contract Determination Appeals (see link in left menu)
- Contract Denial (Initial Application);
- Contract Denial (Service Area Expansion);
- Contract Non-Renewal;
- Contract Termination; and
- Intermediate Sanctions
Medicare Advantage Risk Adjustment Data Validation ("MA RADV") Appeals (see link in left menu)
Medicare Part D Reconciliation Payment Appeals
Medicare Provider Cost Report (< $10K) Appeals
Organ Procurement Organization ("OPO") Appeals
- Cost Report Reimbursement; and
- Decertification
Programs of All-Inclusive Care for the Elderly ("PACE") Appeals
- Contract Termination; and
- Sanctions
Retiree Drug Subsidy ("RDS") Appeals
Other Ad Hoc Appeals
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.