Appeals

40.36 - Appeals (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16) A determination by CMS that a physician or practitioner has failed to properly opt-out, failed to maintain opt-out, failed to timely renew opt-out, failed to privately contract, failed to properly terminate opt-out, or failed to properly cancel opt-out is an initial determination for purposes of 42 CFR 498.3(b). A determination by CMS that no payment can be made to a beneficiary for the services of a physician who has opted out is an initial determination for purposes of 42 CFR 405.924. See the Medicare Claims Processing Manual, Chapter 29, “Appeals of Claims Decisions,” for additional information on appeals.