Contents
- 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.
- 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.
- 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 and Administrator review.
- 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.
- 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.
- 405.2100-405.2101 -405.2101 [Reserved]
- 405.2102 Definitions.
- 405.211 Coverage of items and services in FDA-approved IDE studies.
- 405.2110 Designation of ESRD networks.
- 405.2111 [Reserved]
- 405.2112 ESRD network organizations.
- 405.2113 Medical review board.
- 405.2114 [Reserved]
- 405.212 Medicare Coverage IDE study criteria.
- 405.213 Re-evaluation of a device categorization.
- 405.2131-405.2184 -405.2184 [Reserved]
- 405.215 Confidential commercial and trade secret information.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
Contents
3,364 provisions, too many to show on one page. Open a part or section to read it with its history and connections, or search inside the text.
- 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.
- 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.
- 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 and Administrator review.
- 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.
- 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.
- 405.2100-405.2101 · -405.2101 [Reserved]
- 405.2102 · Definitions.
- 405.211 · Coverage of items and services in FDA-approved IDE studies.
- 405.2110 · Designation of ESRD networks.
- 405.2111 · [Reserved]
- 405.2112 · ESRD network organizations.
- 405.2113 · Medical review board.
- 405.2114 · [Reserved]
- 405.212 · Medicare Coverage IDE study criteria.
- 405.213 · Re-evaluation of a device categorization.
- 405.2131-405.2184 · -405.2184 [Reserved]
- 405.215 · Confidential commercial and trade secret information.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
United States Government work; public domain under 17 U.S.C. § 105.