
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395oo]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 1395oo. Provider Reimbursement Review Board


(a) Establishment

    Any provider of services which has filed a required cost report 
within the time specified in regulations may obtain a hearing with 
respect to such cost report by a Provider Reimbursement Review Board 
(hereinafter referred to as the ``Board'') which shall be established by 
the Secretary in accordance with subsection (h) of this section and 
(except as provided in subsection (g)(2) of this section) any hospital 
which receives payments in amounts computed under subsection (b) or (d) 
of section 1395ww of this title and which has submitted such reports 
within such time as the Secretary may require in order to make payment 
under such section may obtain a hearing with respect to such payment by 
the Board, if--
        (1) such provider--
            (A)(i) is dissatisfied with a final determination of the 
        organization serving as its fiscal intermediary pursuant to 
        section 1395h of this title as to the amount of total program 
        reimbursement due the provider for the items and services 
        furnished to individuals for which payment may be made under 
        this subchapter for the period covered by such report, or
            (ii) is dissatisfied with a final determination of the 
        Secretary as to the amount of the payment under subsection (b) 
        or (d) of section 1395ww of this title,
            (B) has not received such final determination from such 
        intermediary on a timely basis after filing such report, where 
        such report complied with the rules and regulations of the 
        Secretary relating to such report, or
            (C) has not received such final determination on a timely 
        basis after filing a supplementary cost report, where such cost 
        report did not so comply and such supplementary cost report did 
        so comply,

        (2) the amount in controversy is $10,000 or more, and
        (3) such provider files a request for a hearing within 180 days 
    after notice of the intermediary's final determination under 
    paragraph (1)(A)(i), or with respect to appeals under paragraph 
    (1)(A)(ii), 180 days after notice of the Secretary's final 
    determination, or with respect to appeals pursuant to paragraph (1) 
    (B) or (C), within 180 days after notice of such determination would 
    have been received if such determination had been made on a timely 
    basis.

(b) Appeals by groups

    The provisions of subsection (a) of this section shall apply to any 
group of providers of services if each provider of services in such 
group would, upon the filing of an appeal (but without regard to the 
$10,000 limitation), be entitled to such a hearing, but only if the 
matters in controversy involve a common question of fact or 
interpretation of law or regulations and the amount in controversy is, 
in the aggregate, $50,000 or more.

(c) Right to counsel; rules of evidence

    At such hearing, the provider of services shall have the right to be 
represented by counsel, to introduce evidence, and to examine and cross-
examine witnesses. Evidence may be received at any such hearing even 
though inadmissible under rules of evidence applicable to court 
procedure.

(d) Decisions of Board

    A decision by the Board shall be based upon the record made at such 
hearing, which shall include the evidence considered by the intermediary 
and such other evidence as may be obtained or received by the Board, and 
shall be supported by substantial evidence when the record is viewed as 
a whole. The Board shall have the power to affirm, modify, or reverse a 
final determination of the fiscal intermediary with respect to a cost 
report and to make any other revisions on matters covered by such cost 
report (including revisions adverse to the provider of services) even 
though such matters were not considered by the intermediary in making 
such final determination.

(e) Rules and regulations

    The Board shall have full power and authority to make rules and 
establish procedures, not inconsistent with the provisions of this 
subchapter or regulations of the Secretary, which are necessary or 
appropriate to carry out the provisions of this section. In the course 
of any hearing the Board may administer oaths and affirmations. The 
provisions of subsections (d) and (e) of section 405 of this title with 
respect to subpenas shall apply to the Board to the same extent as they 
apply to the Secretary with respect to subchapter II of this chapter.

(f) Finality of decision; judicial review; determinations of Board 
        authority; jurisdiction; venue; interest on amount in 
        controversy

    (1) A decision of the Board shall be final unless the Secretary, on 
his own motion, and within 60 days after the provider of services is 
notified of the Board's decision, reverses, affirms, or modifies the 
Board's decision. Providers shall have the right to obtain judicial 
review of any final decision of the Board, or of any reversal, 
affirmance, or modification by the Secretary, by a civil action 
commenced within 60 days of the date on which notice of any final 
decision by the Board or of any reversal, affirmance, or modification by 
the Secretary is received. Providers shall also have the right to obtain 
judicial review of any action of the fiscal intermediary which involves 
a question of law or regulations relevant to the matters in controversy 
whenever the Board determines (on its own motion or at the request of a 
provider of services as described in the following sentence) that it is 
without authority to decide the question, by a civil action commenced 
within sixty days of the date on which notification of such 
determination is received. If a provider of services may obtain a 
hearing under subsection (a) of this section and has filed a request for 
such a hearing, such provider may file a request for a determination by 
the Board of its authority to decide the question of law or regulations 
relevant to the matters in controversy (accompanied by such documents 
and materials as the Board shall require for purposes of rendering such 
determination). The Board shall render such determination in writing 
within thirty days after the Board receives the request and such 
accompanying documents and materials, and the determination shall be 
considered a final decision and not subject to review by the Secretary. 
If the Board fails to render such determination within such period, the 
provider may bring a civil action (within sixty days of the end of such 
period) with respect to the matter in controversy contained in such 
request for a hearing. Such action shall be brought in the district 
court of the United States for the judicial district in which the 
provider is located (or, in an action brought jointly by several 
providers, the judicial district in which the greatest number of such 
providers are located) or in the District Court for the District of 
Columbia and shall be tried pursuant to the applicable provisions under 
chapter 7 of title 5 notwithstanding any other provisions in section 405 
of this title. Any appeal to the Board or action for judicial review by 
providers which are under common ownership or control or which have 
obtained a hearing under subsection (b) of this section must be brought 
by such providers as a group with respect to any matter involving an 
issue common to such providers.
    (2) Where a provider seeks judicial review pursuant to paragraph 
(1), the amount in controversy shall be subject to annual interest 
beginning on the first day of the first month beginning after the 180-
day period as determined pursuant to subsection (a)(3) of this section 
and equal to the rate of interest on obligations issued for purchase by 
the Federal Hospital Insurance Trust Fund for the month in which the 
civil action authorized under paragraph (1) is commenced, to be awarded 
by the reviewing court in favor of the prevailing party.
    (3) No interest awarded pursuant to paragraph (2) shall be deemed 
income or cost for the purposes of determining reimbursement due 
providers under this chapter.

(g) Certain findings not reviewable

    (1) The finding of a fiscal intermediary that no payment may be made 
under this subchapter for any expenses incurred for items or services 
furnished to an individual because such items or services are listed in 
section 1395y of this title shall not be reviewed by the Board, or by 
any court pursuant to an action brought under subsection (f) of this 
section.
    (2) The determinations and other decisions described in section 
1395ww(d)(7) of this title shall not be reviewed by the Board or by any 
court pursuant to an action brought under subsection (f) of this section 
or otherwise.

(h) Composition and compensation

    The Board shall be composed of five members appointed by the 
Secretary without regard to the provisions of title 5 governing 
appointments in the competitive services. Two of such members shall be 
representative of providers of services. All of the members of the Board 
shall be persons knowledgeable in the field of payment of providers of 
services, and at least one of them shall be a certified public 
accountant. Members of the Board shall be entitled to receive 
compensation at rates fixed by the Secretary, but not exceeding the rate 
specified (at the time the service involved is rendered by such members) 
for grade GS-18 in section 5332 of title 5. The term of office shall be 
three years, except that the Secretary shall appoint the initial members 
of the Board for shorter terms to the extent necessary to permit 
staggered terms of office.

(i) Technical and clerical assistance

    The Board is authorized to engage such technical assistance as may 
be required to carry out its functions, and the Secretary shall, in 
addition, make available to the Board such secretarial, clerical, and 
other assistance as the Board may require to carry out its functions.

(j) ``Provider of services'' defined

    In this section, the term ``provider of services'' includes a rural 
health clinic and a Federally qualified health center.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1878, as added Pub. L. 92-
603, title II, Sec. 243(a), Oct. 30, 1972, 86 Stat. 1420; amended Pub. 
L. 93-484, Sec. 3(a), Oct. 26, 1974, 88 Stat. 1459; Pub. L. 96-499, 
title IX, Sec. 955, Dec. 5, 1980, 94 Stat. 2647; Pub. L. 98-21, title 
VI, Sec. 602(h), Apr. 20, 1983, 97 Stat. 165; Pub. L. 98-369, div. B, 
title III, Secs. 2351(a)(1), (b)(1), 2354(b)(39), (40), July 18, 1984, 
98 Stat. 1098, 1099, 1102; Pub. L. 101-508, title IV, Sec. 4161(a)(6), 
(b)(4), Nov. 5, 1990, 104 Stat. 1388-94, 1388-95; Pub. L. 103-66, title 
XIII, Sec. 13503(c)(1)(B), Aug. 10, 1993, 107 Stat. 579.)

                       References in Text

    The provisions of title 5 governing appointments in the competitive 
service, referred to in subsec. (h), are classified to section 3301 et 
seq. of Title 5, Government Organization and Employees.


                               Amendments

    1993--Subsec. (f)(2). Pub. L. 103-66 substituted ``the rate of 
interest on obligations issued for purchase by the Federal Hospital 
Insurance Trust Fund for the month in which'' for ``the rate of return 
on equity capital established by regulation pursuant to section 
1395x(v)(1)(B) of this title and in effect at the time''.
    1990--Subsec. (j). Pub. L. 101-508, Sec. 4161(b)(4), inserted ``a 
rural health clinic and'' after ``includes''.
    Pub. L. 101-508, Sec. 4161(a)(6), added subsec. (j).
    1984--Subsec. (c). Pub. L. 98-369, Sec. 2354(b)(39), substituted 
``inadmissible'' for ``inadmissable''.
    Subsec. (e). Pub. L. 98-369, Sec. 2354(b)(40), substituted ``and 
(e)'' for ``, (e), and (f)''.
    Subsec. (f)(1). Pub. L. 98-369, Sec. 2351(a)(1), substituted 
``notification of such determination is received'' for ``such 
determination is rendered'' in third sentence.
    Pub. L. 98-369, Sec. 2351(b)(1), inserted ``or which have obtained a 
hearing under subsection (b) of this section'' after ``common ownership 
or control'' in last sentence.
    1983--Subsec. (a). Pub. L. 98-21, Sec. 602(h)(1)(A), inserted 
provision in introductory text that, except as provided in subsec. 
(g)(2) of this section, any hospital which receives payments in amounts 
computed under section 1395ww(b) or (d) of this title and which has 
submitted such reports within such time as Secretary may require in 
order to make payment under such section may obtain a hearing with 
respect to such payment by Board.
    Subsec. (a)(1)(A). Pub. L. 98-21, Sec. 602(h)(1)(B), (C), designated 
existing provisions as cl. (i) and added cl. (ii).
    Subsec. (a)(3). Pub. L. 98-21, Sec. 602(h)(1)(D), substituted 
``(1)(A)(i), or with respect to appeals under paragraph (1)(A)(ii), 180 
days after notice of the Secretary's final determination,'' for 
``(1)(A)''.
    Subsec. (f)(1). Pub. L. 98-21, Sec. 602(h)(2), inserted ``(or, in an 
action brought jointly by several providers, the judicial district in 
which the greatest number of such providers are located)'' after ``the 
judicial district in which the provider is located'', and ``Any appeal 
to the Board or action for judicial review by providers which are under 
common ownership or control must be brought by such providers as a group 
with respect to any matter involving an issue common to such 
providers.''
    Subsec. (g). Pub. L. 98-21, Sec. 602(h)(3), designated existing 
provisions as par. (1) and added par. (2).
    Subsec. (h). Pub. L. 98-21, Sec. 602(h)(4), substituted ``payment of 
providers of services'' for ``cost reimbursement''.
    1980--Subsec. (f)(1). Pub. L. 96-499 inserted provision empowering 
providers of services to obtain judicial review of any action of a 
fiscal intermediary involving a question of law or regulations relevant 
to matters in controversy whenever Board determined that it was without 
authority to decide such matters in controversy.
    1974--Subsec. (f). Pub. L. 93-484 redesignated existing provisions 
as par. (1), inserted provisions authorizing judicial review for 
providers of final decisions of Board and judicial review of any 
affirmance by Secretary, and added pars. (2) and (3).


                    Effective Date of 1993 Amendment

    Amendment by Pub. L. 103-66 effective Oct. 1, 1993, see section 
13503(c)(2) of Pub. L. 103-66, set out as a note under section 1395x of 
this title.


                    Effective Date of 1990 Amendment

    Amendment by section 4161(a)(6) of Pub. L. 101-508 applicable to 
cost reports for periods beginning on or after Oct. 1, 1991, see section 
4161(a)(8)(C) of Pub. L. 101-508, set out as a note under section 1395k 
of this title.
    Amendment by section 4161(b)(4) of Pub. L. 101-508 applicable to 
cost reports for periods beginning on or after Oct. 1, 1991, see section 
4161(b)(5) of Pub. L. 101-508, set out as a note under section 1395x of 
this title.


                    Effective Date of 1984 Amendment

    Section 2351(a)(2) of Pub. L. 98-369 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective with 
respect to any civil action commenced on or after the date of the 
enactment of this Act [July 18, 1984].''
    Section 2351(b)(2) of Pub. L. 98-369 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall be effective with 
respect to any appeal or action brought on or after the date of the 
enactment of this Act [July 18, 1984].''
    Amendment by section 2354(b)(39), (40) of Pub. L. 98-369 effective 
July 18, 1984, but not to be construed as changing or affecting any 
right, liability, status, or interpretation which existed (under the 
provisions of law involved) before that date, see section 2354(e)(1) of 
Pub. L. 98-369, set out as a note under section 1320a-1 of this title.


                    Effective Date of 1983 Amendment

    Amendment by Pub. L. 98-21 applicable to items and services 
furnished by or under arrangement with a hospital beginning with its 
first cost reporting period that begins on or after Oct. 1, 1983, any 
change in a hospital's cost reporting period made after November 1982 to 
be recognized for such purposes only if the Secretary finds good cause 
therefor, see section 604(a)(1) of Pub. L. 98-21, set out as a note 
under section 1395ww of this title. See, also, section 2351(c) of Pub. 
L. 98-369, set out as a note below.


                    Effective Date of 1974 Amendment

    Section 3(b) of Pub. L. 93-484 provided that: ``The amendment made 
by subsection (a) [amending this section] shall be applicable to cost 
reports of providers of services for accounting periods ending on or 
after June 30, 1973.''


                             Effective Date

    Section 243(c) of Pub. L. 92-603 provided that: ``The amendments 
made by this section [enacting this section and amending section 1395h 
of this title] shall apply with respect to cost reports of providers of 
services, as defined in title XVIII of the Social Security Act [this 
subchapter], for accounting periods ending on or after June 30, 1973.''


         References in Other Laws to GS-16, 17, or 18 Pay Rates

    References in laws to the rates of pay for GS-16, 17, or 18, or to 
maximum rates of pay under the General Schedule, to be considered 
references to rates payable under specified sections of Title 5, 
Government Organization and Employees, see section 529 [title I, 
Sec. 101(c)(1)] of Pub. L. 101-509, set out in a note under section 5376 
of Title 5.


         Review of Provider Reimbursement Review Board Decisions

    Section 2351(c) of Pub. L. 98-369 provided that: ``Notwithstanding 
section 604 of the Social Security Amendments of 1983 (Public Law 98-21) 
[set out as an Effective Date of 1983 Amendments note under section 
1395ww of this title]--
        ``(1) the amendments made by section 602(h)(2)(A) of that Act 
    [amending this section] shall be effective with respect to any 
    appeal or action brought on or after April 20, 1983; and
        ``(2) the amendments made by section 602(h)(2)(B) of that Act 
    [amending this section] shall be effective with respect to any 
    appeal or action brought on or after the date of the enactment of 
    this Act [July 18, 1984].''

                  Section Referred to in Other Sections

    This section is referred to in sections 256e, 1395h, 1395i-5, 1395l, 
1395rr, 1395ww, 1395yy, 1395fff of this title.
