Title 42, The Public Health and WelfareRelease 119-73not60
§1320c–4 Right to Hearing and Judicial Review
Title 42 › Chapter 7— SOCIAL SECURITY › Subchapter XI— GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION › Part B— Peer Review of Utilization and Quality of Health Care Services › § 1320c–4
Summary
If a Medicare beneficiary — and in some cases a provider or practitioner — disagrees with a decision by a quality improvement organization, the organization must reconsider the decision. If the result still goes against the beneficiary and the dispute is $200 or more, the beneficiary may have a hearing by the Secretary under section 405(l) (with "Secretary" and "HHS" used in place of the Social Security Commissioner and Administration); if the dispute is $2,000 or more, the beneficiary may seek judicial review.
Full Legal Text
Title 42, §1320c–4
The Public Health and Welfare, Source: USLM XML via OLRC
Any beneficiary who is entitled to benefits under subchapter XVIII, and, subject to section 1320c–3(a)(3)(D) of this title, any practitioner or provider, who is dissatisfied with a determination made by a contracting quality improvement organization in conducting its review responsibilities under this part, shall be entitled to a reconsideration of such determination by the reviewing organization. Where the reconsideration is adverse to the beneficiary and where the matter in controversy is $200 or more, such beneficiary shall be entitled to a hearing by the Secretary (to the same extent as beneficiaries under subchapter II are entitled to a hearing by the Commissioner of Social Security under section 405(b) of this title). For purposes of the preceding sentence, subsection (l) of section 405 of this title shall apply, except that any reference in such subsection to the Commissioner of Social Security or the Social Security Administration shall be deemed a reference to the Secretary or the Department of Health and Human Services, respectively. Where the amount in controversy is $2,000 or more, such beneficiary shall be entitled to judicial review of any final decision relating to a reconsideration described in this subsection.
Legislative History
Notes & Related Subsidiaries
Editorial Notes
Prior Provisions
A prior section 1320c–4, act Aug. 14, 1935, ch. 531, title XI, § 1155, as added Oct. 30, 1972, Pub. L. 92–603, title II, § 249F(b), 86 Stat. 1433; amended Oct. 25, 1977, Pub. L. 95–142, § 5(c)(1), (d)(3), (o)(2), (p), 91 Stat. 1184, 1188, 1191, 1192; Dec. 5, 1980, Pub. L. 96–499, title IX, §§ 924(b)–(d), 925–927(a), 931(g), 94 Stat. 2629, 2630, 2634; Aug. 13, 1981, Pub. L. 97–35, title XXI, §§ 2111, 2113(d), 2121(f), 95 Stat. 793, 794, 796, related to functions and duties of Professional Standards Review Organizations, prior to the general revision of this part by Pub. L. 97–248.
Amendments
2011—Pub. L. 112–40 substituted “quality improvement” for “peer review”. 1994—Pub. L. 103–296 substituted “(to the same extent as beneficiaries under subchapter II are entitled to a hearing by the Commissioner of Social Security under section 405(b) of this title). For purposes of the preceding sentence, subsection (l) of section 405 of this title shall apply, except that any reference in such subsection to the Commissioner of Social Security or the Social Security Administration shall be deemed a reference to the Secretary or the Department of Health and Human Services, respectively. Where the amount in controversy is $2,000 or more, such beneficiary shall be entitled to judicial review of any final decision relating to a reconsideration described in this subsection.” for “(to the same extent as is provided in section 405(b) of this title), and, where the amount in controversy is $2,000 or more, to judicial review of the Secretary’s final decision.” 1989—Pub. L. 101–239 inserted “, subject to section 1320c–3(a)(3)(D) of this title,” before “any practitioner or provider”.
Statutory Notes and Related Subsidiaries
Effective Date
of 2011 AmendmentAmendment by Pub. L. 112–40 applicable to contracts entered into or renewed on or after Jan. 1, 2012, see section 261(e) of Pub. L. 112–40, set out as a note under section 1320c of this title.
Effective Date
of 1994 AmendmentAmendment by Pub. L. 103–296 effective Mar. 31, 1995, see section 110(a) of Pub. L. 103–296, set out as a note under section 401 of this title.
Effective Date
of 1989 AmendmentAmendment by Pub. L. 101–239 applicable to determinations by utilization and quality control peer review organizations with respect to which preliminary notifications were made under section 1320c–3(a)(3)(B) of this title more than 30 days after Dec. 19, 1989, see section 6224(b)(3) of Pub. L. 101–239, set out as a note under section 1320c–3 of this title.
Reference
Citations & Metadata
Citation
42 U.S.C. § 1320c–4
Title 42, The Public Health and Welfare
Last Updated
Apr 5, 2026
Release point: 119-73not60