Find Laws Find Lawyers Free Legal Forms USA State Laws
CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER B—MEDICARE PROGRAM (parts 405 to 426) > PART 422—MEDICARE ADVANTAGE PROGRAM > SUBPART K—--Application Procedures and Contracts for Medicare Advantage Organizations (§422.500 to §422.527) > 422.502—Evaluation and determination procedures.

CFR

422.502—Evaluation and determination procedures.

(a) Basis for evaluation and determination. (1) With the exception of evaluations conducted under paragraph (b) of this section, CMS evaluates an application for an MA contract solely on the basis of information contained in the application itself and any additional information that CMS obtains through other means such as on-site visits.
(2) After evaluating all relevant information, CMS determines whether the applicant's application meets all the requirements described in this part.
(b) Use of information from a current or prior contract. If an MA organization fails during the 14 months preceding the deadline established by CMS for the submission of contract qualification applications to comply with the requirements of the Part C program under any current or prior contract with CMS under title XVIII of the Act or fails to complete a corrective action plan during the 14 months preceding the deadline established by CMS for the submission of contract qualification applications, CMS may deny an application based on the applicant's failure to comply with the requirements of the Part C program under any current or prior contract with CMS even if the applicant currently meets all of the requirements of this part.
(c) Notice of determination. Within timeframes determined by CMS, it notifies each applicant that applies for an MA contract under this part of its determination and the basis for the determination. The determination is one of the following:
(1) Approval of application. If CMS approves the application, it gives written notice to the applicant, indicating that it qualifies to contract as an MA organization.
(2) Intent to deny. (i) If CMS finds that the applicant does not appear to be able to meet the requirements for an MA organization and/or has not provided enough information to evaluate the application, CMS gives the contract applicant notice of intent to deny the application for an MA contract and a summary of the basis for this preliminary finding.
(ii) Within 10 days from the date of the intent to deny notice, the contract applicant must respond in writing to the issues or other matters that were the basis for CMS' preliminary finding and must revise its application to remedy any defects CMS identified.
(iii) If CMS does not receive a revised application within 10 days from the date of the notice, or if after timely submission of a revised application, CMS still finds the applicant does not appear qualified to contract as an MA organization or has not provided enough information to allow CMS to evaluate the application, CMS will deny the application.
(3) Denial of application. If CMS denies the application, it gives written notice to the contract applicant indicating—
(i) That the applicant is not qualified to contract as an MA organization under Part C of title XVIII of the Act;
(ii) The reasons why the applicant is not qualified; and
(iii) The applicant's right to request a hearing in accordance with the procedures specified in subpart N of this part.
[70 FR 4736, Jan. 28, 2005, as amended at 75 FR 19809, Apr. 15, 2010]
Tips