CMS Hearing Officer

The CMS Hearing Officer adjudicates a diverse range of matters brought by healthcare institutions, insurance issuers, state Medicaid agencies, organ procurement organizations, and other entities under various statutory and regulatory authorities for which the Office of Hearings ("OH") serves as “Reviewing Official” or “Presiding Officer.”

Appeal Types & Subtypes

Accountable Care Organization Comprehensive Joint Replacement Program (“ACO-CJR”)

Affordable Care Act ("ACA") Financial Appeals

Cost Plan Reimbursement (e.g., Cost HMO)

Group Health Plan Non-Conformance

Health Maintenance Organization Competitive Medical Plan ("HMO-CMP")

• Contract Denial;
• Contract Non-Renewal;
• Contract Termination; and
• Intermediate Sanctions

Medicaid State Plan

• State Plan Amendment Disapproval; and
• Compliance Determination

Medicare Administrative Contractor Termination

Medicare Advantage/Prescription Drug Plan ("MA/PD")

• Contract Denial (Initial Application);
• Contract Denial (Service Area Expansion);
• Contract Non-Renewal;
• Contract Termination; and
• Intermediate Sanctions

Medicare Advantage Risk Adjustment Data Validation ("MA-RADV") Appeals

Medicare Part D Reconciliation Payment

Medicare Provider Cost Report (< $10K)

Organ Procurement Organization ("OPO")

• Cost Report Reimbursement; and
• Decertification

Programs of All-Inclusive Care for the Elderly ("PACE")

• Contract Termination; and
• Sanctions

Retiree Drug Subsidy ("RDS")

Other Ad Hoc Appeals