§ 417.620 - Responsibility for reconsiderations; time limits.

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

(a) If the HMO or CMP can make a reconsidered determination that is completely favorable to the enrollee, the HMO or CMP issues the reconsidered determination.

(b) If the HMO or CMO recommends partial or complete affirmation of its adverse determination, the HMO or CMP must prepare a written explanation and send the entire case to HFCA. CMS makes the reconsidered datermination.

(c) The HMO or CMP must issue the reconsidered determination to the enrollee, or submit the explanation and file to CMS within 60 calendar days from the date of receipt of the request for reconsideration. In the case of an expedited reconsideration, the HMO or CMP must issue the reconsidered determination as specified in § 417.617(c)(3) or submit the explanation and file to CMS within 24 hours of its determination, the expiration of the 72-hour review period, or the expiration of the extension.

(d) For good cause shown, CMS may allow extensions to the time limit set forth in paragraph (c) of this section.

(e) Failure by the HMO or CMP to provide the enrollee with a reconsidered determination within the time limits described in paragraph (c) of this section or to obtain a good cause extension described in paragraph (d) of this section constitutes an adverse determination, and the HMO or CMP must submit the file to CMS.

(f) If the HMO or CMP refers the matter to CMS, it must concurrently notify the beneficiary of that action.

Effective Date Note:

At 70 FR 4713, Jan. 28, 2005, § 417.620 was removed, effective January 1, 2006.