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Home Page > Executive Branch > Code of Federal Regulations > Electronic Code of Federal Regulations
e-CFR Data is current as of November 19, 2009
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
Subpart A--[RESERVED]
Subpart B--MEDICAL SERVICES COVERAGE DECISIONS THAT RELATE TO HEALTH CARE TECHNOLOGY
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| Scope of subpart and definitions. |
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| FDA categorization of investigational devices. |
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| Coverage of a non-experimental/investigational (Category B) device. |
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| Services related to a noncovered device. |
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| Payment for a non-experimental/investigational (Category B) device. |
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| Procedures for Medicare contractors in making coverage decisions for a non-experimental/investigational (Category B) device. |
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| Re-evaluation of a device categorization. |
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| Confidential commercial and trade secret information. |
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Subpart C--SUSPENSION OF PAYMENT, RECOVERY OF OVERPAYMENTS, AND REPAYMENT OF SCHOLARSHIPS AND LOANS
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| Individual's liability for payments made to providers and other persons for items and services furnished the individual. |
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| Incorrect payments for which the individual is not liable. |
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| Adjustment of title XVIII incorrect payments. |
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| Certification of amount that will be adjusted against individual title II or railroad retirement benefits. |
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| Procedures for adjustment or recovery--title II beneficiary. |
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| Waiver of adjustment or recovery. |
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| Principles applied in waiver of adjustment or recovery. |
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| Notice of right to waiver consideration. |
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| When waiver of adjustment or recovery may be applied. |
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| Liability of certifying or disbursing officer. |
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| Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services. |
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| Proceeding for suspension of payment. |
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| Proceeding for offset or recoupment. |
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| Opportunity for rebuttal. |
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| Time limits for, and notification of, administrative determination after receipt of rebuttal statement. |
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| Suspension and termination of collection action and compromise of claims for overpayment. |
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| Withholding Medicare payments to recover Medicaid overpayments. |
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| Interest charges on overpayment and underpayments to providers, suppliers, and other entities. |
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| Limitation on recoupment of provider and supplier overpayments. |
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| Collection of past-due amounts on scholarship and loan programs. |
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Subpart D--PRIVATE CONTRACTS
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| Conditions for properly opting-out of Medicare. |
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| Requirements of the private contract. |
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| Requirements of the opt-out affidavit. |
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| Effects of opting-out of Medicare. |
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| Failure to properly opt-out. |
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| Failure to maintain opt-out. |
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| Emergency and urgent care services. |
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| Renewal and early termination of opt-out. |
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| Application to Medicare+Choice contracts. |
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Subpart E--CRITERIA FOR DETERMINING REASONABLE CHARGES
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| Determination of reasonable charges. |
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| Criteria for determining reasonable charges. |
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| Determining customary charges. |
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| Determining prevailing charges. |
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| Determination of locality. |
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| Charges higher than customary or prevailing charges or lowest charge levels. |
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| Illustrations of the application of the criteria for determining reasonable charges. |
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| Determination of comparable circumstances; limitation. |
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| Determining the inflation-indexed charge. |
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| Reasonable charges for medical services, supplies, and equipment. |
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| Carriers' procedural terminology and coding systems. |
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| Reimbursement for clinical laboratory services billed by physicians. |
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| Payment for drugs and biologicals that are not paid on a cost or prospective payment basis. |
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| Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services furnished incident to their professional services. |
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| Limitation on payment for screening mammography services. |
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| Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002. |
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Subpart F--[RESERVED]
Subpart G--RECONSIDERATIONS AND APPEALS UNDER MEDICARE PART A
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| Basis, purpose and definitions. |
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| Notice of initial determination. |
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| Actions which are initial determinations. |
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| Actions which are not initial determinations. |
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| Decisions of utilization review committees. |
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| Effect of initial determination. |
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| Right to reconsideration. |
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| Time and place of filing request for reconsideration. |
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| Extension of time to request reconsideration. |
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| Withdrawal of request for reconsideration. |
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| Reconsidered determination. |
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| Notice of reconsidered determination. |
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| Effect of a reconsidered determination. |
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| Expedited appeals process. |
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| Hearing; right to hearing. |
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| Time and place of filing request for a hearing. |
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| Departmental Appeals Board (DAB) review. |
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| Review of a national coverage determination (NCD). |
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| Principles for determining the amount in controversy. |
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| Amount in controversy ascertained after reconsideration. |
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| Dismissal of request for hearing; amount in controversy less than $100. |
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| Time period for reopening initial, revised, or reconsidered determinations and decisions or revised decisions of an ALJ or the Departmental Appeals Board (DAB); binding effect of determination and decisions. |
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| Appeal of a categorization of a device. |
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Subpart H--APPEALS UNDER THE MEDICARE PART B PROGRAM
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| Part B appeals--general description. |
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| Notice of initial determination. |
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| Parties to the initial determination. |
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| Effect of Initial Determination. |
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| Request for review of initial determination. |
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| Opportunity to submit evidence. |
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| Notice of review determination. |
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| Effect of review determination. |
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| Amount in controversy for carrier hearing, ALJ hearing and judicial review. |
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| Principles for determining amount in controversy. |
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| Request for carrier hearing. |
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| Parties to a carrier hearing. |
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| Disqualification of carrier hearing officer. |
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| Location of carrier hearing. |
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| Notice of carrier hearing. |
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| Conduct of the carrier hearing. |
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| Waiver of right to appear at carrier hearing and present evidence. |
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| Dismissal of request for carrier hearing. |
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| Record of carrier hearing. |
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| Carrier hearing officer's decision. |
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| Effect of carrier hearing officer's decision. |
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| Authority of the carrier hearing officer. |
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| Reopening initial or review determination of the carrier, and decision of a carrier hearing officer. |
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| Notice of reopening and revision. |
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| Change of ruling or legal precedent. |
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| Expedited appeals process. |
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| Departmental Appeals Board (DAB) review. |
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| Review of a national coverage determination (NCD). |
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| Appointment of representative. |
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| Qualifications of representatives. |
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| Authority of representatives. |
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| Appeals of CMS or a CMS contractor. |
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| Appeal of a categorization of a device. |
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Subpart I--DETERMINATIONS, REDETERMINATIONS, RECONSIDERATIONS, AND APPEALS UNDER ORIGINAL MEDICARE (PART A AND PART B)
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| Medicare initial determinations, redeterminations and appeals: General description. |
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| Parties to the initial determinations, redeterminations, reconsiderations, hearings and reviews. |
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| Appointed representatives. |
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| Assignment of appeal rights. |
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| Notice of initial determination. |
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| Time frame for processing initial determinations. |
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| Actions that are initial determinations. |
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| Actions that are not initial determinations. |
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| Initial determinations subject to the reopenings process. |
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| Effect of the initial determination. |
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| Right to a redetermination. |
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| Time frame for filing a request for a redetermination. |
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| Place and method of filing a request for a redetermination. |
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| Evidence to be submitted with the redetermination request. |
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| Conduct of a redetermination. |
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| Time frame for making a redetermination. |
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| Withdrawal or dismissal of a request for a redetermination. |
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| Notice of a redetermination. |
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| Effect of a redetermination. |
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| Right to a reconsideration. |
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| Timeframe for filing a request for a reconsideration. |
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| Place and method of filing a request for a reconsideration. |
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| Evidence to be submitted with the reconsideration request. |
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| Conduct of a reconsideration. |
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| Timeframe for making a reconsideration. |
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| Withdrawal or dismissal of a request for a reconsideration. |
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| Notice of a reconsideration. |
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| Effect of a reconsideration. |
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| Reopenings of initial determinations, redeterminations, and reconsiderations, hearings and reviews. |
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| Notice of a revised determination or decision. |
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| Effect of a revised determination or decision. |
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| Good cause for reopening. |
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| Expedited access to judicial review. |
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| Hearing before an ALJ: General rule. |
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| Right to ALJ review of QIC notice of dismissal. |
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| Amount in controversy required to request an ALJ hearing and judicial review. |
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| Parties to an ALJ hearing. |
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| When CMS or its contractors may participate in an ALJ hearing. |
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| When CMS or its contractors may be a party to a hearing. |
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| Request for an ALJ hearing. |
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| Time frames for deciding an appeal before an ALJ. |
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| Submitting evidence before the ALJ hearing. |
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| Time and place for a hearing before an ALJ. |
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| Notice of a hearing before an ALJ. |
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| Objections to the issues. |
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| Disqualification of the ALJ. |
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| Prehearing case review of evidence submitted to the ALJ. |
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| When an ALJ may remand a case to the QIC. |
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| Description of an ALJ hearing process. |
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| Deciding a case without a hearing before an ALJ. |
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| Prehearing and posthearing conferences. |
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| The administrative record. |
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| Consolidated hearing before an ALJ. |
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| Notice of an ALJ decision. |
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| The effect of an ALJ's decision. |
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| Removal of a hearing request from an ALJ to the MAC. |
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| Dismissal of a request for a hearing before an ALJ. |
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| Effect of dismissal of a request for a hearing before an ALJ. |
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| Applicability of national coverage determinations (NCDs). |
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| Applicability of local coverage determinations and other policies not binding on the ALJ and MAC. |
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| Applicability of CMS Rulings. |
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| ALJ decisions involving statistical samples. |
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| Medicare Appeals Council review: General. |
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| Request for MAC review when ALJ issues decision or dismissal. |
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| Request for MAC review when an ALJ does not issue a decision timely. |
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| Where a request for review or escalation may be filed. |
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| MAC actions when request for review or escalation is filed. |
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| MAC reviews on its own motion. |
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| Content of request for review. |
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| Dismissal of request for review. |
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| Effect of dismissal of request for MAC review or request for hearing. |
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| Obtaining evidence from the MAC. |
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| Filing briefs with the MAC. |
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| What evidence may be submitted to the MAC. |
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| Case remanded by the MAC. |
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| Effect of the MAC's decision. |
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| Request for escalation to Federal court. |
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| Extension of time to file action in Federal district court. |
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| Case remanded by a Federal district court. |
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| MAC review of ALJ decision in a case remanded by a Federal district court. |
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Subpart J--EXPEDITED DETERMINATIONS AND RECONSIDERATIONS OF PROVIDER SERVICE TERMINATIONS, AND PROCEDURES FOR INPATIENT HOSPITAL DISCHARGES
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| Notifying beneficiaries of provider service terminations. |
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| Expedited determination procedures. |
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| Expedited reconsiderations. |
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| Notifying beneficiaries of hospital discharge appeal rights. |
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| Expedited determination procedures for inpatient hospital care. |
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| Hospital requests expedited QIO review. |
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Subparts K-Q--[RESERVED]
Subpart R--PROVIDER REIMBURSEMENT DETERMINATIONS AND APPEALS
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| Intermediary determination and notice of amount of program reimbursement. |
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| Matters not subject to administrative and judicial review under prospective payment. |
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| Parties to intermediary determination. |
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| Effect of intermediary determination. |
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| Intermediary hearing procedures. |
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| Right to intermediary hearing; contents of, and adding issues to, hearing request. |
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| Good cause extension of time limit for requesting an intermediary hearing. |
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| Intermediary hearing officer jurisdiction. |
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| Parties to proceedings before the intermediary hearing officer(s). |
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| Hearing officer or panel of hearing officers authorized to conduct intermediary hearing; disqualification of officers. |
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| Conduct of intermediary hearing. |
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| Prehearing discovery and other proceedings prior to the intermediary hearing. |
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| Evidence at intermediary hearing. |
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| Witnesses at intermediary hearing. |
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| Record of proceedings before the intermediary hearing officer(s). |
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| Scope of authority of intermediary hearing officer(s). |
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| Intermediary hearing decision. |
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| Effect of intermediary hearing decision. |
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| CMS reviewing official procedure. |
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| Right to Board hearing; contents of, and adding issues to, hearing request. |
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| Good cause extension of time limit for requesting a Board hearing. |
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| Expedited judicial review. |
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| Parties to proceedings in a Board appeal. |
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| Composition of Board; hearings, decisions, and remands. |
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| Disqualification of Board members. |
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| Establishment of time and place of hearing by the Board. |
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| Conduct of Board hearing. |
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| Board proceedings prior to any hearing; discovery. |
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| Evidence at Board hearing. |
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| Oral argument and written allegations. |
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| Administrative policy at issue. |
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| Record of administrative proceedings. |
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| Scope of Board's legal authority. |
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| Board actions in response to failure to follow Board rules. |
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| Scope of Board's authority in a hearing decision. |
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| Appointment of representative. |
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| Authority of representative. |
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| Reopening an intermediary determination or reviewing entity decision. |
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| Notice of reopening; effect of reopening. |
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| Effect of a revision; issue-specific nature of appeals of revised determinations and decisions. |
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Subparts S-T--[RESERVED]
Subpart U--CONDITIONS FOR COVERAGE OF SUPPLIERS OF END-STAGE RENAL DISEASE (ESRD) SERVICES
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| Designation of ESRD networks. |
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| ESRD network organizations. |
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Subparts V-W--[RESERVED]
Subpart X--RURAL HEALTH CLINIC AND FEDERALLY QUALIFIED HEALTH CENTER SERVICES
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| Content and terms of the agreement with the Secretary. |
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| Terminations of agreements. |
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| Application of Part B deductible and coinsurance. |
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| Services and supplies incident to a physician's services. |
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| Nurse practitioner and physician assistant services. |
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| Services and supplies incident to nurse practitioner and physician assistant services. |
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| Visiting nurse services: Determination of shortage of agencies. |
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| Content and terms of the agreement. |
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| Termination of agreement. |
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| Conditions for reinstatement after termination by CMS. |
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| Preventive primary services. |
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| Clinical psychologist and clinical social worker services. |
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| Services and supplies incident to clinical psychologist and clinical social worker services. |
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| Applicability of general payment exclusions. |
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| Payment for rural health clinic and Federally qualified health center services. |
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| What constitutes a visit. |
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| Federally Qualified Health Centers supplemental payments. |
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| Reports and maintenance of records. |
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