Part 405 — Federal Health Insurance for the Aged and Disabled
Subpart B — Medical Services Coverage Decisions That Relate to Health Care Technology
- § 405.201— Scope of subpart and definitions.
- § 405.203— FDA categorization of investigational devices.
- § 405.205— Coverage of a Category B (Nonexperimental/investigational) device.
- § 405.207— Services related to a noncovered device.
- § 405.209— Payment for a Category B (Nonexperimental/investigational) device.
- § 405.211— Coverage of items and services in FDA-approved IDE studies.
- § 405.212— Medicare Coverage IDE study criteria.
- § 405.213— Re-evaluation of a device categorization.
- § 405.215— Confidential commercial and trade secret information.
Subpart C — Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans
- § 405.301— Scope of subpart.
- § 405.350— Individual's liability for payments made to providers and other persons for items and services furnished the individual.
- § 405.351— Incorrect payments for which the individual is not liable.
- § 405.352— Adjustment of title XVIII incorrect payments.
- § 405.353— Certification of amount that will be adjusted against individual title II or railroad retirement benefits.
- § 405.354— Procedures for adjustment or recovery—title II beneficiary.
- § 405.355— Waiver of adjustment or recovery.
- § 405.356— Principles applied in waiver of adjustment or recovery.
- § 405.357— Notice of right to waiver consideration.
- § 405.358— When waiver of adjustment or recovery may be applied.
- § 405.359— Liability of certifying or disbursing officer.
- § 405.370— Definitions.
- § 405.371— Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
- § 405.372— Proceeding for suspension of payment.
- § 405.373— Proceeding for offset or recoupment.
- § 405.374— Opportunity for rebuttal.
- § 405.375— Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
- § 405.376— Suspension and termination of collection action and compromise of claims for overpayment.
- § 405.377— Withholding Medicare payments to recover Medicaid overpayments.
- § 405.378— Interest charges on overpayment and underpayments to providers, suppliers, and other entities.
- § 405.379— Limitation on recoupment of provider and supplier overpayments.
- § 405.380— Collection of past-due amounts on scholarship and loan programs.
Subpart D — Private Contracts
- § 405.400— Definitions.
- § 405.405— General rules.
- § 405.410— Conditions for properly opting-out of Medicare.
- § 405.415— Requirements of the private contract.
- § 405.420— Requirements of the opt-out affidavit.
- § 405.425— Effects of opting-out of Medicare.
- § 405.430— Failure to properly opt-out.
- § 405.435— Failure to maintain opt-out.
- § 405.440— Emergency and urgent care services.
- § 405.445— Cancellation of opt-out and early termination of opt-out.
- § 405.450— Appeals.
- § 405.455— Application to Medicare Advantage contracts.
Subpart E — Criteria for Determining Reasonable Charges
- § 405.500— Basis.
- § 405.501— Determination of reasonable charges.
- § 405.502— Criteria for determining reasonable charges.
- § 405.503— Determining customary charges.
- § 405.504— Determining prevailing charges.
- § 405.505— Determination of locality.
- § 405.506— Charges higher than customary or prevailing charges or lowest charge levels.
- § 405.507— Illustrations of the application of the criteria for determining reasonable charges.
- § 405.508— Determination of comparable circumstances; limitation.
- § 405.509— Determining the inflation-indexed charge.
- § 405.511— Reasonable charges for medical services, supplies, and equipment.
- § 405.512— Carriers' procedural terminology and coding systems.
- § 405.515— Reimbursement for clinical laboratory services billed by physicians.
- § 405.517— Payment for drugs and biologicals that are not paid on a cost or prospective payment basis.
- § 405.520— Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services furnished incident to their professional services.
- § 405.534— Limitation on payment for screening mammography services.
- § 405.535— Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002.
Subpart H — Appeals Under the Medicare Part B Program
- § 405.800— Appeals of CMS or a CMS contractor.
- § 405.803— Appeals rights.
- § 405.806— Impact of reversal of contractor determinations on claims processing.
- § 405.809— Reinstatement of provider or supplier billing privileges following corrective action.
- § 405.812— Effective date for DMEPOS supplier's billing privileges.
- § 405.815— Submission of claims.
- § 405.818— Deadline for processing provider enrollment initial determinations.
Subpart I — Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)
- § 405.900— Basis and scope.
- § 405.902— Definitions.
- § 405.903— Prepayment review.
- § 405.904— Medicare initial determinations, redeterminations and appeals: General description.
- § 405.906— Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.
- § 405.908— Medicaid State agencies.
- § 405.910— Appointed representatives.
- § 405.912— Assignment of appeal rights.
- § 405.920— Initial determinations.
- § 405.921— Notice of initial determination.
- § 405.922— Time frame for processing initial determinations.
- § 405.924— Actions that are initial determinations.
- § 405.925— Decisions of utilization review committees.
- § 405.926— Actions that are not initial determinations.
- § 405.927— Initial determinations subject to the reopenings process.
- § 405.928— Effect of the initial determination.
- § 405.929— Post-payment review.
- § 405.930— Failure to respond to additional documentation request.
- § 405.931— Scope, basis, and definitions.
- § 405.932— Right to appeal a denial of Part A coverage resulting from a change in patient status.
- § 405.934— Reconsideration.
- § 405.936— Hearings before an ALJ and decisions by an ALJ or Attorney Adjudicator.
- § 405.938— Review by the Medicare Appeals Council and judicial review.
- § 405.940— Right to a redetermination.
- § 405.942— Time frame for filing a request for a redetermination.
- § 405.944— Place and method of filing a request for a redetermination.
- § 405.946— Evidence to be submitted with the redetermination request.
- § 405.947— Notice to the beneficiary of applicable plan's request for a redetermination.
- § 405.948— Conduct of a redetermination.
- § 405.950— Time frame for making a redetermination.
- § 405.952— Withdrawal or dismissal of a request for a redetermination.
- § 405.954— Redetermination.
- § 405.956— Notice of a redetermination.
- § 405.958— Effect of a redetermination.
- § 405.960— Right to a reconsideration.
- § 405.962— Timeframe for filing a request for a reconsideration.
- § 405.964— Place and method of filing a request for a reconsideration.
- § 405.966— Evidence to be submitted with the reconsideration request.
- § 405.968— Conduct of a reconsideration.
- § 405.970— Timeframe for making a reconsideration following a contractor redetermination.
- § 405.972— Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.
- § 405.974— Reconsideration and review of a contractor's dismissal of a request for redetermination.
- § 405.976— Notice of a reconsideration.
- § 405.978— Effect of a reconsideration.
- § 405.980— Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.
- § 405.982— Notice of a revised determination or decision.
- § 405.984— Effect of a revised determination or decision.
- § 405.986— Good cause for reopening.
- § 405.990— Expedited access to judicial review.
- § 405.1000— Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
- § 405.1002— Right to an ALJ hearing.
- § 405.1004— Right to a review of QIC notice of dismissal.
- § 405.1006— Amount in controversy required for an ALJ hearing and judicial review.
- § 405.1008— Parties to the proceedings on a request for an ALJ hearing.
- § 405.1010— When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.
- § 405.1012— When CMS or its contractors may be a party to a hearing.
- § 405.1014— Request for an ALJ hearing or a review of a QIC dismissal.
- § 405.1016— Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.
- § 405.1018— Submitting evidence.
- § 405.1020— Time and place for a hearing before an ALJ.
- § 405.1022— Notice of a hearing before an ALJ.
- § 405.1024— Objections to the issues.
- § 405.1026— Disqualification of the ALJ or attorney adjudicator.
- § 405.1028— Review of evidence submitted by parties.
- § 405.1030— ALJ hearing procedures.
- § 405.1032— Issues before an ALJ or attorney adjudicator.
- § 405.1034— Requesting information from the QIC.
- § 405.1036— Description of an ALJ hearing process.
- § 405.1037— Discovery.
- § 405.1038— Deciding a case without a hearing before an ALJ.
- § 405.1040— Prehearing and posthearing conferences.
- § 405.1042— The administrative record.
- § 405.1044— Consolidated proceedings.
- § 405.1046— Notice of an ALJ or attorney adjudicator decision.
- § 405.1048— The effect of an ALJ's or attorney adjudicator's decision.
- § 405.1050— Removal of a hearing request from OMHA to the Council.
- § 405.1052— Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.
- § 405.1054— Effect of dismissal of a request for a hearing or request for review of QIC dismissal.
- § 405.1056— Remands of requests for hearing and requests for review.
- § 405.1058— Effect of a remand.
- § 405.1060— Applicability of national coverage determinations (NCDs).
- § 405.1062— Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.
- § 405.1063— Applicability of laws, regulations, CMS Rulings, and precedential decisions.
- § 405.1100— Medicare Appeals Council review: General.
- § 405.1102— Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
- § 405.1106— Where a request for review or escalation may be filed.
- § 405.1108— Council actions when request for review or escalation is filed.
- § 405.1110— Council reviews on its own motion.
- § 405.1112— Content of request for review.
- § 405.1114— Dismissal of request for review.
- § 405.1116— Effect of dismissal of request for Council review or request for hearing.
- § 405.1118— Obtaining evidence from the Council.
- § 405.1120— Filing briefs with the Council.
- § 405.1122— What evidence may be submitted to the Council.
- § 405.1124— Oral argument.
- § 405.1126— Case remanded by the Council.
- § 405.1128— Action of the Council.
- § 405.1130— Effect of the Council's decision.
- § 405.1132— Request for escalation to Federal court.
- § 405.1134— Extension of time to file action in Federal district court.
- § 405.1136— Judicial review.
- § 405.1138— Case remanded by a Federal district court.
- § 405.1140— Council review of ALJ decision in a case remanded by a Federal district court.
Subpart J — Procedures and Beneficiary Rights for Expedited Determinations and Reconsiderations When Coverage is Changed or Terminated
- § 405.1200— Notifying beneficiaries of provider service terminations.
- § 405.1202— Expedited determination procedures.
- § 405.1204— Expedited reconsiderations.
- § 405.1205— Notifying beneficiaries of hospital discharge appeal rights.
- § 405.1206— Expedited determination procedures for inpatient hospital care.
- § 405.1208— Hospital requests expedited QIO review.
- § 405.1210— Notifying eligible beneficiaries of appeal rights when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
- § 405.1211— Expedited determination procedures when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
- § 405.1212— Expedited reconsideration procedures regarding Part A coverage when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
Subpart R — Provider Reimbursement Determinations and Appeals
- § 405.1801— Introduction.
- § 405.1803— Contractor determination and notice of amount of program reimbursement.
- § 405.1804— Matters not subject to administrative and judicial review under prospective payment.
- § 405.1805— Parties to contractor determination.
- § 405.1807— Effect of contractor determination.
- § 405.1809— Contractor hearing procedures.
- § 405.1811— Right to contractor hearing; contents of, and adding issues to, hearing request.
- § 405.1813— Good cause extension of time limit for requesting a contractor hearing.
- § 405.1814— Contractor hearing officer jurisdiction.
- § 405.1815— Parties to proceedings before the contractor hearing officer(s).
- § 405.1817— Hearing officer or panel of hearing officers authorized to conduct contractor hearing; disqualification of officers.
- § 405.1819— Conduct of contractor hearing.
- § 405.1821— Prehearing discovery and other proceedings prior to the contractor hearing.
- § 405.1823— Evidence at contractor hearing.
- § 405.1825— Witnesses at contractor hearing.
- § 405.1827— Record of proceedings before the contractor hearing officer(s).
- § 405.1829— Scope of authority of contractor hearing officer(s).
- § 405.1831— Contractor hearing decision.
- § 405.1832— Contractor hearing officer review of compliance with the substantive reimbursement requirement of an appropriate cost report claim.
- § 405.1833— Effect of contractor hearing decision.
- § 405.1834— CMS reviewing official procedure.
- § 405.1835— Right to Board hearing; contents of, and adding issues to, hearing request.
- § 405.1836— Good cause extension of time limit for requesting a Board hearing.
- § 405.1837— Group appeals.
- § 405.1839— Amount in controversy.
- § 405.1840— Board jurisdiction.
- § 405.1842— Expedited judicial review.
- § 405.1843— Parties to proceedings in a Board appeal.
- § 405.1845— Composition of Board; hearings, decisions, and remands.
- § 405.1847— Disqualification of Board members.
- § 405.1849— Establishment of time and place of hearing by the Board.
- § 405.1851— Conduct of Board hearing.
- § 405.1853— Board proceedings prior to any hearing; discovery.
- § 405.1855— Evidence at Board hearing.
- § 405.1857— Subpoenas.
- § 405.1859— Witnesses.
- § 405.1861— Oral argument and written allegations.
- § 405.1863— Administrative policy at issue.
- § 405.1865— Record of administrative proceedings.
- § 405.1867— Scope of Board's legal authority.
- § 405.1868— Board actions in response to failure to follow Board rules.
- § 405.1869— Scope of Board's authority in a hearing decision.
- § 405.1871— Board hearing decision.
- § 405.1873— Board review of compliance with the reimbursement requirement of an appropriate cost report claim.
- § 405.1875— Administrator review.
- § 405.1877— Judicial review.
- § 405.1881— Appointment of representative.
- § 405.1883— Authority of representative.
- § 405.1885— Reopening a contractor determination or reviewing entity decision.
- § 405.1887— Notice of reopening; effect of reopening.
- § 405.1889— Effect of a revision; issue-specific nature of appeals of revised determinations and decisions.
Subpart U — Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services
Subpart X — Rural Health Clinic and Federally Qualified Health Center Services
- § 405.2400— Basis.
- § 405.2401— Scope and definitions.
- § 405.2402— Rural health clinic basic requirements.
- § 405.2403— Rural health clinic content and terms of the agreement with the Secretary.
- § 405.2404— Termination of rural health clinic agreements.
- § 405.2410— Application of Part B deductible and coinsurance.
- § 405.2411— Scope of benefits.
- § 405.2412— Physicians' services.
- § 405.2413— Services and supplies incident to a physician's services.
- § 405.2414— Nurse practitioner, physician assistant, and certified nurse midwife services.
- § 405.2415— Incident to services and direct supervision.
- § 405.2416— Visiting nurse services.
- § 405.2417— Visiting nurse services: Determination of shortage of agencies.
- § 405.2430— Basic requirements.
- § 405.2434— Content and terms of the agreement.
- § 405.2436— Termination of agreement.
- § 405.2440— Conditions for reinstatement after termination by CMS.
- § 405.2442— Notice to the public.
- § 405.2444— Change of ownership.
- § 405.2446— Scope of services.
- § 405.2448— Preventive primary services.
- § 405.2449— Preventive services.
- § 405.2450— Clinical psychologist, clinical social worker, marriage and family therapist, and mental health counselor services.
- § 405.2452— Services and supplies incident to clinical psychologist, clinical social worker, marriage and family therapist, and mental health counselor services.
- § 405.2460— Applicability of general payment exclusions.
- § 405.2462— Payment for RHC and FQHC services.
- § 405.2463— What constitutes a visit.
- § 405.2464— Payment rate.
- § 405.2466— Annual reconciliation.
- § 405.2467— Requirements of the FQHC PPS.
- § 405.2468— Allowable costs.
- § 405.2469— FQHC supplemental payments.
- § 405.2470— Reports and maintenance of records.
- § 405.2472— Beneficiary appeals.