This regulation establishes the administrative appeals process for hospice providers that believe their Medicare payments have been improperly determined. Hospices may request review from the intermediary or the Provider Reimbursement Review Board (PRRB) depending on the amount in controversy ($1,000 or $10,000 threshold, respectively). The PRRB has authority to determine disputed issues, subject to Secretarial review, but CMS's methods and standards for calculating statutory payment rates are not appealable.
View official source§ 418.311 Administrative appeals. A hospice that believes its payments have not been properly determined in accordance with these regulations may request a review from the intermediary or the Provider Reimbursement Review Board (PRRB) if the amount in controversy is at least $1,000 or $10,000, respectively. In such a case, the procedure in 42 CFR part 405, subpart R, will be followed to the extent that it is applicable. The PRRB, subject to review by the Secretary under § 405.1875 of this chapter, shall have the authority to determine the issues raised. The methods and standards for the calculation of the statutorily defined payment rates by CMS are not subject to appeal. [74 FR 39414, Aug. 6, 2009, as amended at 78 FR 48281, Aug. 7, 2013]