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Code of Federal Regulations Title 42. Public Health § 42.460.124 Additional appeal rights under Medicare or Medicaid

Current as of January 02, 2025 | Updated by Findlaw Staff

<For applicability date(s) of amendment(s) to section, see 86 FR 5864.>

A PACE organization must inform a participant in writing of his or her appeal rights under Medicare or Medicaid managed care, or both, assist the participant in choosing which to pursue if both are applicable, and forward the appeal to the appropriate external entity.

(a) Appeal rights under Medicare. Medicare participants have the right to a reconsideration by an independent review entity.

(1) A written request for reconsideration must be filed with the independent review entity within 60 calendar days from the date of the decision by the third party reviewer under § 460.122.

(2) The independent outside entity must conduct the review as expeditiously as the participant's health condition requires but must not exceed the deadlines specified in the contract.

(3) If the independent review entity conducts a reconsideration, the parties to the reconsideration are the same parties described in § 460.122(c)(2), with the addition of the PACE organization.

(b) Appeal rights under Medicaid. Medicaid participants have the right to a State Fair Hearing as described in part 431, subpart E, of this chapter.

(c) Appeal rights for dual eligible participants. Participants who are eligible for both Medicare and Medicaid have the right to external review by means of either the Independent Review Entity described in paragraph (a) of this section or the State Fair Hearing process described in paragraph (b) of this section.

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Cite this article: FindLaw.com - Code of Federal Regulations Title 42. Public Health § 42.460.124 Additional appeal rights under Medicare or Medicaid - last updated January 02, 2025 | https://codes.findlaw.com/cfr/title-42-public-health/cfr-sect-42-460-124/

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