§ 422.560 Basis and scope
§ 422.561 Definitions
§ 422.562 General provisions
§ 422.564 Grievance procedures
§ 422.566 Organization determinations
§ 422.568 Standard timeframes and notice requirements for organization determinations
§ 422.570 Expediting certain organization determinations
§ 422.572 Timeframes and notice requirements for expedited organization determinations
§ 422.574 Parties to the organization determination
§ 422.576 Effect of an organization determination
§ 422.578 Right to a reconsideration
§ 422.580 Reconsideration defined
§ 422.582 Request for a standard reconsideration
§ 422.584 Expediting certain reconsiderations
§ 422.586 Opportunity to submit evidence
§ 422.590 Timeframes and responsibility for reconsiderations
§ 422.592 Reconsideration by an independent entity
§ 422.594 Notice of reconsidered determination by the independent entity
§ 422.596 Effect of a reconsidered determination
§ 422.600 Right to a hearing
§ 422.602 Request for an ALJ hearing
§ 422.608 Medicare Appeals Council (Council) review
§ 422.612 Judicial review
§ 422.616 Reopening and revising determinations and decisions
§ 422.618 How an MA organization must effectuate standard reconsidered determinations or decisions
§ 422.619 How an MA organization must effectuate expedited reconsidered determinations
§ 422.620 Notifying enrollees of hospital discharge appeal rights
§ 422.622 Requesting immediate QIO review of the decision to discharge from the inpatient hospital
§ 422.624 Notifying enrollees of termination of provider services
§ 422.626 Fast-track appeals of service terminations to independent review entities (IREs)
Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans

Terms Used In CFR > Title 42 > Chapter IV > Subchapter B > Part 422 > Subpart M - Grievances, Organization Determinations and Appeals

  • ALJ: includes a member or members of the Departmental Appeals Board who are designated to conduct a hearing. See 42 CFR 422.1024
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Contract: A legal written agreement that becomes binding when signed.
  • Dependent: A person dependent for support upon another.
  • Dismissal: The dropping of a case by the judge without further consideration or hearing. Source:
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
  • Testimony: Evidence presented orally by witnesses during trials or before grand juries.