Decision of the CMS Administrator

40.3 – Decision of the CMS Administrator Medicare Advantage Contract Determinations and Appeals (Rev. 122, Issued: 05-27-16, Effective: 06-28-16, Implementation: 06-28-16) This chapter discusses Medicare Advantage (MA) contract determinations and appeals as outlined in 42 CFR §422.641-696. Please also note, per 42 CFR §417.640, the rights, procedures, and requirements relating to contract determinations and appeals set forth in part 422 subpart N of the regulations also apply to Medicare cost reimbursement contracts with health maintenance organizations (HMOs) or competitive medical plans (CMPs) under section 1876 of the Act. There are generally four possible steps in the MA contract appeals process. These steps are: 1. A contract determination; 2. A hearing; 3. A review by the CMS Administrator; and, 4. In some cases, a reopening of the contract determination, hearing officer decision, or CMS Administrator decision.