Home/CFR/Title 42/Part 405
FEDERAL · 42 CFR

Part 405 — Federal Health Insurance for the Aged and Disabled

272 sections · Title 42: Public Health

§ 405.201Scope of subpart and definitions.
§ 405.203FDA categorization of investigational devices.
§ 405.205Coverage of a Category B (Nonexperimental/investigational) device.
§ 405.207Services related to a noncovered device.
§ 405.209Payment for a Category B (Nonexperimental/investigational) device.
§ 405.211Coverage of items and services in FDA-approved IDE studies.
§ 405.212Medicare Coverage IDE study criteria.
§ 405.213Re-evaluation of a device categorization.
§ 405.215Confidential commercial and trade secret information.
§ 405.301Scope of subpart.
§ 405.350Individual's liability for payments made to providers and other persons for items and services furnished the individual.
§ 405.351Incorrect payments for which the individual is not liable.
§ 405.352Adjustment of title XVIII incorrect payments.
§ 405.353Certification of amount that will be adjusted against individual title II or railroad retirement benefits.
§ 405.354Procedures for adjustment or recovery—title II beneficiary.
§ 405.355Waiver of adjustment or recovery.
§ 405.356Principles applied in waiver of adjustment or recovery.
§ 405.357Notice of right to waiver consideration.
§ 405.358When waiver of adjustment or recovery may be applied.
§ 405.359Liability of certifying or disbursing officer.
§ 405.370Definitions.
§ 405.371Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
§ 405.372Proceeding for suspension of payment.
§ 405.373Proceeding for offset or recoupment.
§ 405.374Opportunity for rebuttal.
§ 405.375Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
§ 405.376Suspension and termination of collection action and compromise of claims for overpayment.
§ 405.377Withholding Medicare payments to recover Medicaid overpayments.
§ 405.378Interest charges on overpayment and underpayments to providers, suppliers, and other entities.
§ 405.379Limitation on recoupment of provider and supplier overpayments.
§ 405.380Collection of past-due amounts on scholarship and loan programs.
§ 405.400Definitions.
§ 405.405General rules.
§ 405.410Conditions for properly opting-out of Medicare.
§ 405.415Requirements of the private contract.
§ 405.420Requirements of the opt-out affidavit.
§ 405.425Effects of opting-out of Medicare.
§ 405.430Failure to properly opt-out.
§ 405.435Failure to maintain opt-out.
§ 405.440Emergency and urgent care services.
§ 405.445Cancellation of opt-out and early termination of opt-out.
§ 405.450Appeals.
§ 405.455Application to Medicare Advantage contracts.
§ 405.500Basis.
§ 405.501Determination of reasonable charges.
§ 405.502Criteria for determining reasonable charges.
§ 405.503Determining customary charges.
§ 405.504Determining prevailing charges.
§ 405.505Determination of locality.
§ 405.506Charges higher than customary or prevailing charges or lowest charge levels.
§ 405.507Illustrations of the application of the criteria for determining reasonable charges.
§ 405.508Determination of comparable circumstances; limitation.
§ 405.509Determining the inflation-indexed charge.
§ 405.511Reasonable charges for medical services, supplies, and equipment.
§ 405.512Carriers' procedural terminology and coding systems.
§ 405.515Reimbursement for clinical laboratory services billed by physicians.
§ 405.517Payment for drugs and biologicals that are not paid on a cost or prospective payment basis.
§ 405.520Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services furnished incident to their professional services.
§ 405.534Limitation on payment for screening mammography services.
§ 405.535Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002.
§ 405.800Appeals of CMS or a CMS contractor.
§ 405.803Appeals rights.
§ 405.806Impact of reversal of contractor determinations on claims processing.
§ 405.809Reinstatement of provider or supplier billing privileges following corrective action.
§ 405.812Effective date for DMEPOS supplier's billing privileges.
§ 405.815Submission of claims.
§ 405.818Deadline for processing provider enrollment initial determinations.
§ 405.900Basis and scope.
§ 405.902Definitions.
§ 405.903Prepayment review.
§ 405.904Medicare initial determinations, redeterminations and appeals: General description.
§ 405.906Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.
§ 405.908Medicaid State agencies.
§ 405.910Appointed representatives.
§ 405.912Assignment of appeal rights.
§ 405.920Initial determinations.
§ 405.921Notice of initial determination.
§ 405.922Time frame for processing initial determinations.
§ 405.924Actions that are initial determinations.
§ 405.925Decisions of utilization review committees.
§ 405.926Actions that are not initial determinations.
§ 405.927Initial determinations subject to the reopenings process.
§ 405.928Effect of the initial determination.
§ 405.929Post-payment review.
§ 405.930Failure to respond to additional documentation request.
§ 405.931Scope, basis, and definitions.
§ 405.932Right to appeal a denial of Part A coverage resulting from a change in patient status.
§ 405.934Reconsideration.
§ 405.936Hearings before an ALJ and decisions by an ALJ or Attorney Adjudicator.
§ 405.938Review by the Medicare Appeals Council and judicial review.
§ 405.940Right to a redetermination.
§ 405.942Time frame for filing a request for a redetermination.
§ 405.944Place and method of filing a request for a redetermination.
§ 405.946Evidence to be submitted with the redetermination request.
§ 405.947Notice to the beneficiary of applicable plan's request for a redetermination.
§ 405.948Conduct of a redetermination.
§ 405.950Time frame for making a redetermination.
§ 405.952Withdrawal or dismissal of a request for a redetermination.
§ 405.954Redetermination.
§ 405.956Notice of a redetermination.
§ 405.958Effect of a redetermination.
§ 405.960Right to a reconsideration.
§ 405.962Timeframe for filing a request for a reconsideration.
§ 405.964Place and method of filing a request for a reconsideration.
§ 405.966Evidence to be submitted with the reconsideration request.
§ 405.968Conduct of a reconsideration.
§ 405.970Timeframe for making a reconsideration following a contractor redetermination.
§ 405.972Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.
§ 405.974Reconsideration and review of a contractor's dismissal of a request for redetermination.
§ 405.976Notice of a reconsideration.
§ 405.978Effect of a reconsideration.
§ 405.980Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.
§ 405.982Notice of a revised determination or decision.
§ 405.984Effect of a revised determination or decision.
§ 405.986Good cause for reopening.
§ 405.990Expedited access to judicial review.
§ 405.1000Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
§ 405.1002Right to an ALJ hearing.
§ 405.1004Right to a review of QIC notice of dismissal.
§ 405.1006Amount in controversy required for an ALJ hearing and judicial review.
§ 405.1008Parties to the proceedings on a request for an ALJ hearing.
§ 405.1010When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.
§ 405.1012When CMS or its contractors may be a party to a hearing.
§ 405.1014Request for an ALJ hearing or a review of a QIC dismissal.
§ 405.1016Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.
§ 405.1018Submitting evidence.
§ 405.1020Time and place for a hearing before an ALJ.
§ 405.1022Notice of a hearing before an ALJ.
§ 405.1024Objections to the issues.
§ 405.1026Disqualification of the ALJ or attorney adjudicator.
§ 405.1028Review of evidence submitted by parties.
§ 405.1030ALJ hearing procedures.
§ 405.1032Issues before an ALJ or attorney adjudicator.
§ 405.1034Requesting information from the QIC.
§ 405.1036Description of an ALJ hearing process.
§ 405.1037Discovery.
§ 405.1038Deciding a case without a hearing before an ALJ.
§ 405.1040Prehearing and posthearing conferences.
§ 405.1042The administrative record.
§ 405.1044Consolidated proceedings.
§ 405.1046Notice of an ALJ or attorney adjudicator decision.
§ 405.1048The effect of an ALJ's or attorney adjudicator's decision.
§ 405.1050Removal of a hearing request from OMHA to the Council.
§ 405.1052Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.
§ 405.1054Effect of dismissal of a request for a hearing or request for review of QIC dismissal.
§ 405.1056Remands of requests for hearing and requests for review.
§ 405.1058Effect of a remand.
§ 405.1060Applicability of national coverage determinations (NCDs).
§ 405.1062Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.
§ 405.1063Applicability of laws, regulations, CMS Rulings, and precedential decisions.
§ 405.1100Medicare Appeals Council review: General.
§ 405.1102Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
§ 405.1106Where a request for review or escalation may be filed.
§ 405.1108Council actions when request for review or escalation is filed.
§ 405.1110Council reviews on its own motion.
§ 405.1112Content of request for review.
§ 405.1114Dismissal of request for review.
§ 405.1116Effect of dismissal of request for Council review or request for hearing.
§ 405.1118Obtaining evidence from the Council.
§ 405.1120Filing briefs with the Council.
§ 405.1122What evidence may be submitted to the Council.
§ 405.1124Oral argument.
§ 405.1126Case remanded by the Council.
§ 405.1128Action of the Council.
§ 405.1130Effect of the Council's decision.
§ 405.1132Request for escalation to Federal court.
§ 405.1134Extension of time to file action in Federal district court.
§ 405.1136Judicial review.
§ 405.1138Case remanded by a Federal district court.
§ 405.1140Council review of ALJ decision in a case remanded by a Federal district court.
§ 405.1200Notifying beneficiaries of provider service terminations.
§ 405.1202Expedited determination procedures.
§ 405.1204Expedited reconsiderations.
§ 405.1205Notifying beneficiaries of hospital discharge appeal rights.
§ 405.1206Expedited determination procedures for inpatient hospital care.
§ 405.1208Hospital requests expedited QIO review.
§ 405.1210Notifying eligible beneficiaries of appeal rights when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
§ 405.1211Expedited determination procedures when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
§ 405.1212Expedited reconsideration procedures regarding Part A coverage when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
§ 405.1801Introduction.
§ 405.1803Contractor determination and notice of amount of program reimbursement.
§ 405.1804Matters not subject to administrative and judicial review under prospective payment.
§ 405.1805Parties to contractor determination.
§ 405.1807Effect of contractor determination.
§ 405.1809Contractor hearing procedures.
§ 405.1811Right to contractor hearing; contents of, and adding issues to, hearing request.
§ 405.1813Good cause extension of time limit for requesting a contractor hearing.
§ 405.1814Contractor hearing officer jurisdiction.
§ 405.1815Parties to proceedings before the contractor hearing officer(s).
§ 405.1817Hearing officer or panel of hearing officers authorized to conduct contractor hearing; disqualification of officers.
§ 405.1819Conduct of contractor hearing.
§ 405.1821Prehearing discovery and other proceedings prior to the contractor hearing.
§ 405.1823Evidence at contractor hearing.
§ 405.1825Witnesses at contractor hearing.
§ 405.1827Record of proceedings before the contractor hearing officer(s).
§ 405.1829Scope of authority of contractor hearing officer(s).
§ 405.1831Contractor hearing decision.
§ 405.1832Contractor hearing officer review of compliance with the substantive reimbursement requirement of an appropriate cost report claim.
§ 405.1833Effect of contractor hearing decision.
§ 405.1834CMS reviewing official procedure.
§ 405.1835Right to Board hearing; contents of, and adding issues to, hearing request.
§ 405.1836Good cause extension of time limit for requesting a Board hearing.
§ 405.1837Group appeals.
§ 405.1839Amount in controversy.
§ 405.1840Board jurisdiction.
§ 405.1842Expedited judicial review.
§ 405.1843Parties to proceedings in a Board appeal.
§ 405.1845Composition of Board; hearings, decisions, and remands.
§ 405.1847Disqualification of Board members.
§ 405.1849Establishment of time and place of hearing by the Board.
§ 405.1851Conduct of Board hearing.
§ 405.1853Board proceedings prior to any hearing; discovery.
§ 405.1855Evidence at Board hearing.
§ 405.1857Subpoenas.
§ 405.1859Witnesses.
§ 405.1861Oral argument and written allegations.
§ 405.1863Administrative policy at issue.
§ 405.1865Record of administrative proceedings.
§ 405.1867Scope of Board's legal authority.
§ 405.1868Board actions in response to failure to follow Board rules.
§ 405.1869Scope of Board's authority in a hearing decision.
§ 405.1871Board hearing decision.
§ 405.1873Board review of compliance with the reimbursement requirement of an appropriate cost report claim.
§ 405.1875Administrator review.
§ 405.1877Judicial review.
§ 405.1881Appointment of representative.
§ 405.1883Authority of representative.
§ 405.1885Reopening a contractor determination or reviewing entity decision.
§ 405.1887Notice of reopening; effect of reopening.
§ 405.1889Effect of a revision; issue-specific nature of appeals of revised determinations and decisions.
§ 405.2100-405.2101§§ 405.2100-405.2101 [Reserved]
§ 405.2102Definitions.
§ 405.2110Designation of ESRD networks.
§ 405.2111§ 405.2111 [Reserved]
§ 405.2112ESRD network organizations.
§ 405.2113Medical review board.
§ 405.2114§ 405.2114 [Reserved]
§ 405.2131-405.2184§§ 405.2131-405.2184 [Reserved]
§ 405.2400Basis.
§ 405.2401Scope and definitions.
§ 405.2402Rural health clinic basic requirements.
§ 405.2403Rural health clinic content and terms of the agreement with the Secretary.
§ 405.2404Termination of rural health clinic agreements.
§ 405.2410Application of Part B deductible and coinsurance.
§ 405.2411Scope of benefits.
§ 405.2412Physicians' services.
§ 405.2413Services and supplies incident to a physician's services.
§ 405.2414Nurse practitioner, physician assistant, and certified nurse midwife services.
§ 405.2415Incident to services and direct supervision.
§ 405.2416Visiting nurse services.
§ 405.2417Visiting nurse services: Determination of shortage of agencies.
§ 405.2430Basic requirements.
§ 405.2434Content and terms of the agreement.
§ 405.2436Termination of agreement.
§ 405.2440Conditions for reinstatement after termination by CMS.
§ 405.2442Notice to the public.
§ 405.2444Change of ownership.
§ 405.2446Scope of services.
§ 405.2448Preventive primary services.
§ 405.2449Preventive services.
§ 405.2450Clinical psychologist, clinical social worker, marriage and family therapist, and mental health counselor services.
§ 405.2452Services and supplies incident to clinical psychologist, clinical social worker, marriage and family therapist, and mental health counselor services.
§ 405.2460Applicability of general payment exclusions.
§ 405.2462Payment for RHC and FQHC services.
§ 405.2463What constitutes a visit.
§ 405.2464Payment rate.
§ 405.2466Annual reconciliation.
§ 405.2467Requirements of the FQHC PPS.
§ 405.2468Allowable costs.
§ 405.2469FQHC supplemental payments.
§ 405.2470Reports and maintenance of records.
§ 405.2472Beneficiary appeals.