← Glossary · CMS & regulatory
Overturned decision
A plan decision reversed in whole or in part, either by the plan on reconsideration or by the IRE, ALJ or MAC.
On reconsideration, the plan may overturn its own determination and notify the enrollee. A decision can also be reversed in whole or in part by the IRE, ALJ or MAC, after which the plan must effectuate it within the protocol's timeframes. Table 4 includes cases fully or partially overturned and excludes those dismissed or upheld.
Sources: ODAG protocol, Timeliness 1.11, PDF p. 8; Universe Table 4 guidance, PDF p. 34; CDAG protocol, Timeliness 1.10-1.14, pp. 6-7; Universe Table 5, p. 49.