42 CFR Part 405
PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
- PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- Subpart A [Reserved]
- 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
- General Provisions
- § 405.301 Scope of subpart.
- Liability for Payments To Providers or Suppliers and Handling of Incorrect Payments
- § 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.
- Suspension and Recoupment of Payment to Providers and Suppliers and Collection and Compromise of Overpayments
- § 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.
- Repayment of Scholarships and Loans
- § 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.
- Subparts F- G [Reserved]
- 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.
- Initial Determinations
- § 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.
- Retrospective Appeals for Changes in Patient Status That Resulted in Denial of Part A Coverage for Hospital Services
- § 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.
- Redeterminations
- § 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.
- Reconsideration
- § 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.
- Reopenings
- § 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.
- Expedited Access to Judicial Review
- § 405.990 Expedited access to judicial review.
- ALJ Hearings
- § 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.
- Applicability of Medicare Coverage Policies
- § 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.
- Medicare Appeals Council Review
- § 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.
- Subparts K-Q [Reserved]
- 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.
- Subparts S-T [Reserved]
- Subpart U—Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services
- §§ 405.2100-405.2101 [Reserved]
- § 405.2102 Definitions.
- § 405.2110 Designation of ESRD networks.
- § 405.2111 [Reserved]
- § 405.2112 ESRD network organizations.
- § 405.2113 Medical review board.
- § 405.2114 [Reserved]
- §§ 405.2131-405.2184 [Reserved]
- Subparts V-W [Reserved]
- 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.
- Federally Qualified Health Center Services
- § 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.
- Payment for Rural Health Clinic and Federally Qualified Health Center 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.
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