[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: 42CFR431.220]



[Page 37]

 

                         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.  431.220  When a hearing is required.



    (a) The State agency must grant an opportunity for a hearing to the 

following:

    (1) Any applicant who requests it because his claim for services is 

denied or is not acted upon with reasonable promptness.

    (2) Any recipient who requests it because he or she believes the 

agency has taken an action erroneously.

    (3) Any resident who requests it because he or she believes a 

skilled nursing facility or nursing facility has erroneously determined 

that he or she must be transferred or discharged.

    (4) Any individual who requests it because he or she believes the 

State has made an erroneous determination with regard to the 

preadmission and annual resident review requirements of section 

1919(e)(7) of the Act.

    (5) Any MCO or PIHP enrollee who is entitled to a hearing under 

subpart F of part 438 of this chapter.

    (6) Any PAHP enrollee who has an action as stated in this subpart.

    (7) Any enrollee who is entitled to a hearing under subpart B of 

part 438 of this chapter.

    (b) The agency need not grant a hearing if the sole issue is a 

Federal or State law requiring an automatic change adversely affecting 

some or all recipients.



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

67 FR 41095, June 14, 2002; 67 FR 65505, Oct. 25, 2002]