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SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals

HALLEX
Volume I

Transmittal No. I-5-5-3

Division 5: Temporary Instructions

Subject: Medicare Appeals Under Section 1886(f)(2) of the Act

Background

Section 1886 (f)(2) of the Social Security Act provides specific actions which may be taken when a hospital circumvents the prospective payment system (PPS) through unnecessary admissions, readmissions and other inappropriate medical practices. Specifically, payment may be denied for inpatient hospital services with respect to the unnecessary admission or readmission.

Explanation of Content and Changes

This Temporary Instruction (TI) informs OHA components of peer review organization (PRO) instructions defining the types of prohibited actions which circumvent the prospective payment system and outlines corrective actions which a peer review organization will take when it determines that such practices have occurred.

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Insert TI-5-503

Date: September 14, 1987