US Code

Public Law 119-88 (05/04/2026)

42 U.S.C. § 1395oo

Provider Reimbursement Review Board

(a)

Establishment

section 1395ww of this titleAny 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) and (except as provided in subsection (g)(2)) any hospital which receives payments in amounts computed under subsection (b) or (d) of 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)
section 1395h of this title is dissatisfied with a final determination of the organization serving as its fiscal intermediary pursuant to 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)
section 1395ww of this title is dissatisfied with a final determination of the Secretary as to the amount of the payment under subsection (b) or (d) of ,
(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) 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

section 405 of this titleThe 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 with respect to subpenas shall apply to the Board to the same extent as they apply to the Secretary with respect to subchapter II.

(f)

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

(1)
section 405 of this title 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) 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 . 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) 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) 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)
section 1395y of this title 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 shall not be reviewed by the Board, or by any court pursuant to an action brought under subsection (f).
(2)
section 1395ww(d)(7) of this title The determinations and other decisions described in shall not be reviewed by the Board or by any court pursuant to an action brought under subsection (f) or otherwise.
(h)

Composition and compensation

section 5332 of title 5The 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 . 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 Pub. L. 92–603, title II, § 243(a)86 Stat. 1420 Pub. L. 93–484, § 3(a)88 Stat. 1459 Pub. L. 96–499, title IX, § 95594 Stat. 2647 Pub. L. 98–21, title VI, § 602(h)97 Stat. 165 Pub. L. 98–369, div. B, title III98 Stat. 1098 Pub. L. 101–508, title IV, § 4161(a)(6)104 Stat. 1388–94 Pub. L. 103–66, title XIII, § 13503(c)(1)(B)107 Stat. 579 (, title XVIII, § 1878, as added , , ; amended , , ; , , ; , , ; , §§ 2351(a)(1), (b)(1), 2354(b)(39), (40), , , 1099, 1102; , (b)(4), , , 1388–95; , , .)

Editorial Notes

Amendments

Pub. L. 103–66section 1395x(v)(1)(B) of this title1993—Subsec. (f)(2). 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 and in effect at the time”.

Pub. L. 101–508, § 4161(b)(4)1990—Subsec. (j). , inserted “a rural health clinic and” after “includes”.

Pub. L. 101–508, § 4161(a)(6), added subsec. (j).

Pub. L. 98–369, § 2354(b)(39)1984—Subsec. (c). , substituted “inadmissible” for “inadmissable”.

Pub. L. 98–369, § 2354(b)(40)Subsec. (e). , substituted “and (e)” for “, (e), and (f)”.

Pub. L. 98–369, § 2351(a)(1)Subsec. (f)(1). , substituted “notification of such determination is received” for “such determination is rendered” in third sentence.

Pub. L. 98–369, § 2351(b)(1), inserted “or which have obtained a hearing under subsection (b)” after “common ownership or control” in last sentence.

Pub. L. 98–21, § 602(h)(1)(A)1983—Subsec. (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.

Pub. L. 98–21, § 602(h)(1)(B)Subsec. (a)(1)(A). , (C), designated existing provisions as cl. (i) and added cl. (ii).

Pub. L. 98–21, § 602(h)(1)(D)Subsec. (a)(3). , 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)”.

Pub. L. 98–21, § 602(h)(2)Subsec. (f)(1). , 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.”

Pub. L. 98–21, § 602(h)(3)Subsec. (g). , designated existing provisions as par. (1) and added par. (2).

Pub. L. 98–21, § 602(h)(4)Subsec. (h). , substituted “payment of providers of services” for “cost reimbursement”.

Pub. L. 96–4991980—Subsec. (f)(1). 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.

Pub. L. 93–4841974—Subsec. (f). 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).

Statutory Notes and Related Subsidiaries

Effective Date of 1993 Amendment

Pub. L. 103–66section 13503(c)(2) of Pub. L. 103–66section 1395x of this titleAmendment by effective , see , set out as a note under .

Effective Date of 1990 Amendment

section 4161(a)(6) of Pub. L. 101–508section 4161(a)(8)(C) of Pub. L. 101–508section 1395k of this titleAmendment by applicable to cost reports for periods beginning on or after , see , set out as a note under .

section 4161(b)(4) of Pub. L. 101–508section 4161(b)(5) of Pub. L. 101–508section 1395x of this titleAmendment by applicable to cost reports for periods beginning on or after , see , set out as a note under .

Effective Date of 1984 Amendment

Pub. L. 98–369, div. B, title III, § 2351(a)(2)98 Stat. 1099

“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 [].”
, , , provided that:

Pub. L. 98–369, div. B, title III, § 2351(b)(2)98 Stat. 1099

“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 [].”
, , , provided that:

Pub. L. 98–369section 2354(e)(1) of Pub. L. 98–369section 1320a–1 of this titleAmendment by section 2354(b)(39), (40) of effective , 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 , set out as a note under .

Effective Date of 1983 Amendment

Pub. L. 98–21section 604(a)(1) of Pub. L. 98–21section 1395ww of this titlesection 2351(c) of Pub. L. 98–369Amendment by 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 , 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 , set out as a note under . See, also, , set out as a note below.

Effective Date of 1974 Amendment

Pub. L. 93–484, § 3(b)88 Stat. 1459

“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 .”
, , , provided that:

Effective Date

Pub. L. 92–603, title II, § 243(c)86 Stat. 1422

section 1395h of this title42 U.S.C. 1395“The amendments made by this section [enacting this section and amending ] shall apply with respect to cost reports of providers of services, as defined in title XVIII of the Social Security Act [ et seq.], for accounting periods ending on or after .”
, , , provided that:

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

Pub. L. 101–509section 5376 of Title 5References 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, § 101(c)(1)] of , set out in a note under .

Review of Provider Reimbursement Review Board Decisions

Pub. L. 98–369, div. B, title III, § 2351(c)98 Stat. 1099

Public Law 98–21section 1395ww of this title“Notwithstanding section 604 of the Social Security Amendments of 1983 () [set out as an Effective Date of 1983 Amendments note under ]—
“(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 ; 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 [].”
, , , provided that: