[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: 42CFR431.201]



[Page 35]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 431_STATE ORGANIZATION AND GENERAL ADMINISTRATION--Table of Contents

 

          Subpart E_Fair Hearings for Applicants and Recipients

 

Sec.  431.201  Definitions.



    For purposes of this subpart:

    Action means a termination, suspension, or reduction of Medicaid 

eligibility or covered services. It also means determinations by skilled 

nursing facilities and nursing facilities to transfer or discharge 

residents and adverse determinations made by a State with regard to the 

preadmission screening and annual resident review requirements of 

section 1919(e)(7) of the Act.

    Adverse determination means a determination made in accordance with 

sections 1919(b)(3)(F) or 1919(e)(7)(B) of the Act that the individual 

does not require the level of services provided by a nursing facility or 

that the individual does or does not require specialized services.

    Date of action means the intended date on which a termination, 

suspension, reduction, transfer or discharge becomes effective. It also 

means the date of the determination made by a State with regard to the 

preadmission screening and annual resident review requirements of 

section 1919(e)(7) of the Act.

    De novo hearing means a hearing that starts over from the beginning.

    Evidentiary hearing means a hearing conducted so that evidence may 

be presented.

    Notice means a written statement that meets the requirements of 

Sec.  431.210.

    Request for a hearing means a clear expression by the applicant or 

recipient, or his authorized representative, that he wants the 

opportunity to present his case to a reviewing authority.

    Service authorization request means a managed care enrollee's 

request for the provision of a service.



[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 

67 FR 41095, June 14, 2002]