§ 417.608 - Notice of adverse organization determination.

Link to an amendment published at 70 FR 4713, Jan. 28, 2005.

(a) If an HMO or CMP makes an organization determination that is partially or fully adverse to the enrollee, it must notify the enrollee of the determination—

(1) Within 60 days of receiving the enrollee's request for payment for services; or

(2) As specified in § 417.609(c)(3) for expedited organization determinations.

(b) The notice must—

(1) State the specific reasons for the determination; and

(2) Inform the enrollee of his or her right to a reconsideration, including the right to and conditions for obtaining an expedited reconsidered determination.

(c) The failure to provide the enrollee with timely notification of an adverse organization determination as specified in paragraph (a) of this section or in § 417.609(b) (concerning time frames for expediting certain organization determinations) constitutes an adverse organization determination and may be appealed.

Effective Date Note:

At 70 FR 4713, Jan. 28, 2005, § 417.608 was removed, effective January 1, 2006.