[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR430.42]



[Page 13]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 430_GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS--Table of 

 

Subpart C_Grants; Reviews and Audits; Withholding for Failure To Comply; 

   Deferral and Disallowance of Claims; Reduction of Federal Medicaid 

                                Payments

 

Sec.  430.42  Disallowance of claims for FFP.



    (a) Notice of disallowance and of right to reconsideration. When the 

Regional Administrator or the Administrator determines that a claim or 

portion of claim is not allowable, he or she promptly sends the State a 

disallowance letter that includes the following, as appropriate:

    (1) The date or dates on which the State's claim for FFP was made.

    (2) The time period during which the expenditures in question were 

made or claimed to have been made.

    (3) The date and amount of any payment or notice of deferral.

    (4) A statement of the amount of FFP claimed, allowed, and 

disallowed and the manner in which these amounts were computed.

    (5) Findings of fact on which the disallowance determination is 

based or a reference to other documents previously furnished to the 

State or included with the notice (such as a report of a financial 

review or audit) which contain the findings of fact on which the 

disallowance determination is based.

    (6) Pertinent citations to the law, regulations, guides and 

instructions supporting the action taken.

    (7) A request that the State make appropriate adjustment in a 

subsequent expenditure report.

    (8) Notice of the State's right to request reconsideration of the 

disallowance and the time allowed to make the request.

    (9) A statement indicating that the disallowance letter is the 

Department's final decision unless the State requests reconsideration 

under paragraph (b)(2) of this section.

    (b) Reconsideration of FFP disallowance. (1) The Departmental 

Appeals Board reviews disallowances of FFP under title XIX.

    (2) A State that wishes to request reconsideration must submit the 

request to the Chair, Departmental Appeals Board, within 30 days after 

receipt of the disallowance letter, and include--

    (i) A copy of the disallowance letter;

    (ii) A statement of the amount in dispute; and

    (iii) A brief statement of why the disallowance is wrong.

    (c) Reconsideration procedures. The reconsideration procedures are 

those set forth in 45 CFR part 16 for Medicaid and for many other 

programs administered by the Department.

    (d) Implementation of decisions. If the reconsideration decision 

requires an adjustment of FFP, either upward or downward, a subsequent 

grant award promptly reflects the amount of increase or decrease.



[53 FR 36571, Sept. 21, 1988, as amended at 56 FR 8846, Mar. 1, 1991]