HI 00208.035 Role of the Division of Reimbursement, Recovery and Reconsideration Evaluation, Bureau
of Program Operations
The Division of Reimbursement, Recovery, and Reconsideration Evaluation is primarily
responsible for directing the processing of CMS appeals and overpayments, and planning,
directing and coordinating the monitoring of Medicare and Medicaid Program guidelines
designed to review and evaluate CMS reimbursement and accounting policy. Some of the
Division’s specific functions are as follows:
The adjudication of requests for reconsideration of Part A claim denials initially
processed by intermediaries, which are unable to conduct their own reconsiderations.
The evaluation of intermediaries’ performance in processing Part A appeals and the
preparation of reports from which intermediaries are rated for Contractor Performance
Evaluation Program purposes.
The review of all Medicare, Medicaid, and PSRO decisions on which a hearing before
the Office of Disability Adjudication and Review (ODAR) has been requested.
The final review of all Part A Medicare and Medicaid decisions by ODAR on health insurance
The evaluation and review of Medicare beneficiary, provider, and physician /supplier
overpayment cases, and the determination and adjudication of recovery actions.