Adjudication Authority

1008 - Adjudication Authority (Rev. 1, 05-21-04) 1008A - Medicare Approval (Rev. 1, 05-21-04) The authority of the Secretary of DHHS to approve, disapprove, or terminate the Medicare participation of certified providers and suppliers is delegated to CMS’ ROs. The authority of the Secretary of DHHS to approve, disapprove, or terminate the CLIA certification of laboratories is delegated to the CMS ROs. EXCEPTION If termination is on the grounds of fraud, program abuse, or noncompliance with peer review requirements, the authority to terminate or to establish eligibility for reinstatement reposes with the Office of Inspector General (OIG), DHHS. 1008B - Medicaid Approval (Rev. 1, 05-21-04) With the exception of State-operated Medicaid-only NFs, Medicaid law requires that the same SA that makes the certifications for Medicare provider and supplier eligibility also makes the determinations for Medicaid eligibility. The law also requires that there be a designated State Medicaid Agency (SMA) responsible for the overall management of the Medicaid program. See 42 CFR 431.610. For State-operated Medicaid-only NFs, §1919 of the Act specifies that the Secretary will have enforcement authority. There is in each State an SMA that is ultimately responsible to CMS for the Medicaid program administration. Each SMA must enter into an interagency agreement with the certifying SA to establish the adjudicative function of the certifying SA and provide for the application of Federal certification standards and procedures. The SMA must accept the SA's certification decisions as final, but it exercises its own determination as to whether to enter into agreements with the approved providers. See Subsection E of this manual. 1008C - Compliance With Title VI of the Civil Rights Act of 1964 (Rev. 1, 05-21-04) Providers are direct recipients of Federal funds and are thus subject to title VI of the Civil Rights Act of 1964. The U.S. Office for Civil Rights (OCR) has the authority to determine whether Medicare providers comply with this non-discrimination statute, and the conditions of participation (CoPs) make OCR approval a requirement for Medicare approval by CMS. Before OCR will issue its approval, it also determines compliance with §504 of the Rehabilitation Act of 1973, as amended by the Rehabilitation Act Amendments of 1974, which includes a cross reference to the Uniformed Federal Accessibility Standards concerning architectural barriers to the handicapped. The OCR must also determine compliance with the Age Discrimination Act of 1975, and with title IX of the Education Amendments of 1972. See 45 CRF Part 84; see also Exhibit 2 of this manual. Regarding Medicaid-only providers, the States themselves are considered the direct recipients of the Federal funds and may be considered to have a direct obligation to assure OCR of their compliance by assuring that funds go to providers who are in compliance. As with Medicare, determinations of civil rights compliance of providers are under the authority of OCR and are preconditions to approving the provider's participation in the Medicaid program. 1008D - Waivers of Standards (Rev. 93, Issued: 11-29-13, Effective: 11-29-13, Implementation: 11-29-13) For a few of the standards, the statute or regulations allow for waivers in the presence of verified temporary shortages of health personnel or in the presence of equivalent alternative patient safeguards. Medicare waiver authority is re-delegated to the ROs. Waivers for NFs to provide licensed personnel on a 24-hour basis repose with the States. Life safety code waivers for NFs and ICFs/IID are the responsibility of the States [See 42 CFR 483.470(j)(2)(A)]. 1008E - Look-Behind Authority (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) The Secretary has authority under §§1902(a)(33), 1919(g)(3), and 1910(b)(1) of the Act to cancel approval of all Medicaid facilities, including NFs, PRTFs, ICF/IIDs, Medicaid- only hospitals, and HHAs that do not meet Federal health or safety requirements. Such a determination is in lieu of, or overrides, a determination by the State and is binding on the SMA. Section 1902(a)(33) gives CMS the authority to question State determinations regarding Medicaid facilities' compliance with Federal requirements and authorizes CMS to make independent and binding determinations concerning the extent to which individual institutions and agencies meet requirements for participation. Section 1919(g)(3)(A) states that if the State determines that an individual NF meets Federal requirements, but CMS determines that the facility does not meet such requirements, CMS’ determination as to the facility's noncompliance is binding and supersedes that of the State. Section 1910(b)(1), the look-behind authority, gives CMS similar authority to terminate the Medicaid approval of ICFs/IID. The CMS’ decision to cancel the approval or terminate an ICFs/IID can be made as the result of complaint or Federal validation surveys or CMS’ review of SA survey findings. CMS also may, under 42 CFR Part 442.30, invalidate a Medicaid provider agreement after determining that the agreement does not constitute valid evidence of the provider's compliance with the Federal regulatory requirements. In the latter situation, the effect is to deny and recoup all Federal matching funds in the Medicaid payments to the facilities that were made under the improper agreement. The authority to investigate and either cancel approval or invalidate improper agreements, called "old" look-behind authority, is re-delegated to an office in each CMS RO. 1008F - Authorization of Certification Expenditures (Rev. 1, 05-21-04) Authority to approve Medicare certification budgets and expenditures is re-delegated to CMS’ regional administrators (RAs). Authority to approve or disapprove Federal financial participation (FFP) in Medicaid certification expenses is re-delegated to the RAs subject to ratification by CMS. 1008G - Appeals (Rev. 1, 05-21-04) All of the appeal authorities do not repose with CMS. All CMS RO notices of adverse determinations include instructions on the proper filing and addressing of the appropriate appeal. 1008H - Compliance With TRICARE of Uniformed Services and/or Civilian Health and Medical Program of Veterans Administration (CHAMPVA) Requirements (Rev. 1, 05-21-04) For the provision of inpatient hospital services pursuant to admissions occurring on or after January 1, 1987, providers are required to participate in the TRICARE/CHAMPVA programs. As mandated by §1866(a)(1)(J) of the Act, providers are subject to implementing regulations governing TRICARE/CHAMPVA programs benefits under title 10, §1079 or §1086 of chapter 55 - Medical and Dental Care of the TRICARE; and title 38, §613 of chapter 17 - Hospital, Nursing Home, Domiciliary, and Medical Care of the CHAMPVA. Such regulations are found in 32 CFR Part 199 for TRICARE and 38 CFR 17.54 for CHAMPVA. Inpatient hospital care to TRICARE and/or CHAMPVA beneficiaries is subject to the specific eligibility and medical service limitations set forth in the regulations. Hospitals are to accept TRICARE and/or CHAMPVA reimbursement for such services as payment in full. The Secretary has authority under §1866(b)(2) of the Act to terminate provider agreements for noncompliance. See 42 CFR 489.25. NOTE: This requirement relates to individuals whose inpatient care is covered under the TRICARE and CHAMPVA programs, not to Medicare beneficiaries who, though eligible for these programs, are using Medicare as the primary payer for their services. (See the Medicare Benefit Policy Manual, Pub 100-02, Chapter 16, §50.) 1008I - Compliance With Veteran’s Administration (VA) Program Requirements (Rev. 1, 05-21-04) For the provision of inpatient hospital services pursuant to admissions occurring on or after July 1, 1987, providers must agree to be a participating provider of care to VA patients. As mandated by §1866(a)(1)(L) of the Act, providers are subject to implementing regulations governing VA program benefits under title 38, §603. The provision of inpatient hospital care to veterans is subject to the specific limitations set forth in 38 CFR 17.50(b). Hospitals must accept VA reimbursement for such services as payment in full. The Secretary has authority under §1866(b)(2) of the Act to terminate provider agreements for noncompliance. See 42 CFR 489.26. NOTE: This requirement relates to veterans, whose inpatient care is covered under the VA program, not to Medicare beneficiaries who are also eligible for VA coverage. (See the Medicare Benefit Policy Manual, Pub 100-02, Chapter 16, §50.)