US · guidance
CMS Pub. 100-08, ch. 4, § 4.7.4.2
Reversed Denials by Administrative Law Judges on Open
Cases
(Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23)
If a case is still pending at the OIG, FBI, or AUSA, and denials are reversed by an
Administrative Law Judge (ALJ), the UPIC should recommend to CMS that it consider
protesting the ALJ’s decision to the DHHS Appeals Council, which has the authority to
remand or reverse the ALJ’s decision. UPICs should be aware, however, that ALJs are
bound only by statutory and administrative law (federal regulations), CMS rulings, and
National Coverage Determinations.
The UPIC shall consult with its BFL, with a copy to the COR, before initiating a protest
of an ALJ’s decision. They should be aware that the Appeals Council has only 60 days
in which to decide whether to review an ALJ’s decisions. Thus, CMS needs to protest
the ALJ decision within 30 days of the decision, to allow the Appeals Council to review
within the 60-day limit. The UPIC shall notify all involved parties immediately if it
learns that claims/claim denials have been reversed by an ALJ in a case pending
prosecution.
History
(Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
fd24fa571c2ed614f5e0b4ae173371606384b15e08290b1dce25fc3eba20f92d
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