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Regulatory Procedures for Board Review

Part 16 of  45 C.F.R. sets out the procedures for Board review in the types of cases described in the Appendix to Part 16.  Some federal components have issued regulations that provide for Board review in those or other types of cases using modified Part 16 procedures or other procedures.  Those regulations include the following:

  • 20 C.F.R. Part 498, for review of decisions of administrative law judges regarding civil money penalties proposed by the Inspector General, Social Security Administration, under the Social Security Act (see also Guidelines);
  • 21 C.F.R. Part 17, for review of decisions of administrative law judges (outside the DAB) regarding civil money penalties under the Federal Food, Drug, and Cosmetic Act and the Public Health Service Act (see also Guidelines);
  • 21 C.F.R. Part 900, for review of decisions of administrative law judges regarding certification or recertification of mammography facilities (adopting  procedures in 42 C.F.R. Part 498);
  • 25 C.F.R. Part 900, subpart L, for review of decisions of administrative law judges (outside the DAB) regarding contract declinations under title I of the Indian Self-Determination and Education Assistance Act (review authority pursuant to delegation by the Secretary) (see also Guidelines);
  • 42 C.F.R. Part 3, subpart D, for review of decisions of administrative law judges regarding civil money penalties for violations of the confidentiality provisions of the Patient Safety and Quality Improvement Act (see also Guidelines);
  • 42 C.F.R. Part 137, subpart P, for review of decisions of administrative law judges (outside the DAB) regarding certain pre-award disputes involving compacts, funding agreements, and construction project agreements under title V of the Indian Self-Determination and Education Assistance Act (review authority pursuant to delegation by the Secretary);
  • 42 C.F.R. Part 402, subpart A, for review of decisions of administrative law judges regarding civil money penalties, assessments and exclusions under the statutory authorities listed in section 402.1 (adopting procedures in 42 C.F.R. Part 1005);
  • 42 C.F.R. Part 422, subpart T, for review of decisions of administrative law judges regarding civil money penalties imposed on Medicare Advantage organizations;
  • 42 C.F.R. Part 423, subpart T, for review of decisions of administrative law judges regarding civil money penalties imposed on Medicare Part D plan sponsors;
  • 42 C.F.R. Part 426, subpart D, for review of decisions of administrative law judges regarding Medicare local coverage determinations;
  • 42 C.F.R. Part 426, subpart E, for review of complaints concerning Medicare national coverage determinations;
  • 42 C.F.R. Part 493, subpart R, for review of decisions of administrative law judges regarding sanctions or remedies imposed on laboratories under the Clinical Laboratory Improvement Amendments of 1988 and related statutes (adopting the procedures in 42 C.F.R. Part 498) (see also Guidelines);
  • 42 C.F.R. Part 498, for review of decisions of administrative law judges 1) regarding certain determinations affecting providers’ or prospective providers’ participation in the Medicare and Medicaid programs and certain determinations affecting only Medicaid participation (see also Guidelines), or 2) affecting a provider’s or supplier’s enrollment in the Medicare program (see also Guidelines);
  • 42 C.F.R. Part 1004, subpart F, section 1004.140(b), for review of decisions of administrative law judges regarding exclusions of practitioners from participation in the Medicare and Medicaid programs where no determination is made within 120 days on a Quality Improvement Organization’s recommendation for exclusion (modifying procedures at 42 C.F.R. Part 1005);
  • 42 C.F.R. Part 1005, for review of decisions of administrative law judges regarding exclusions from participation in the Medicare and Medicaid programs and civil money penalties under 42C.F.R.Parts 1001, 1003, and 1004 (see also Guidelines);
  • 45 C.F.R. Part 79, for review of decisions of administrative law judges regarding liability for civil penalties or assessments under the Program Fraud Civil Remedies Act (see also Guidelines);
  • 45 C.F.R. Parts 80 and 81, for review of decisions of administrative law judges regarding enforcement of the Civil Rights Act of 1964, related statutes, and 504 of the Rehabilitation Act (review authority pursuant to Secretarial appointment of individual Board Members as Civil Rights Reviewing Authority) (see also Guidelines);
  • 45 C.F.R. Part 96, section 96.52, for review of decisions resulting from hearings held by a presiding officer on repayment of block grant funds or, if a referral is made by the Secretary, decisions resulting from hearings held by a presiding officer on withholding of block grant funds; 
  • 45 C.F.R. Part 160, subpart E, for review of decisions of administrative law judges regarding civil money penalties for violations of standards implementing the administrative simplification provisions of the Health Insurance Portability and Accountability Act (see also Guidelines);
  • 45 C.F.R. Part 262, section 262.7, for review of penalties under the Temporary Assistance for Needy Families program;
  • 45 C.F.R. Part 286, section 286.240, for review of penalties under the Tribal Temporary Assistance for Needy Families program;  
  • 45 C.F.R. Part 286, section 286.170, for review of disapprovals of Tribal Family Assistance plans or plan amendments;
  • 45 C.F.R. Part 1303, subparts A and B, for review of certain suspensions, terminations and denials of refunding of Head Start grants (except Early Head Start); 
  • 45 C.F.R. Part 1336, subpart C, section 1336.35, for review of determinations of ineligibility for grants under sections 804 and 805 of the Native American Programs Act;
  • 45 C.F.R. Part 1355, section 1355.39, for review of withholdings of Social Security Act title IV-B and IV-E funds for nonconformity with State plan requirements and of reductions of IV-E funds for non-compliance with provisions for removal of barriers to interethnic adoption.

In addition, section 1116(e) of the Social Security Act (42 U.S.C. § 1316(e)) modifies the Part 16 procedures for cases involving Medicaid disallowances.

Last Revised: March 17, 2010