CFR /  Title 42  /  Part 405: Federal Health Insurance For The Aged And Disabled

Section No.	Description
Section 405.201	FDA categorization of investigational devices
Section 405.203	Coverage of a Category B (Nonexperimental/investigational) device
Section 405.205	Services related to a noncovered device
Section 405.207	Payment for a Category B (Nonexperimental/investigational) device
Section 405.209	Coverage of items and services in FDA-approved IDE studies
Section 405.211	Medicare Coverage IDE study criteria
Section 405.212	Re-evaluation of a device categorization
Section 405.213	Confidential commercial and trade secret information
Section 405.215	Scope of subpart
Section 405.301	Individual's liability for payments made to providers and other persons for items and services furnished the individual
Section 405.350	Incorrect payments for which the individual is not liable
Section 405.351	Adjustment of title XVIII incorrect payments
Section 405.352	Certification of amount that will be adjusted against individual title II or railroad retirement benefits
Section 405.353	Procedures for adjustment or recovery--title II beneficiary
Section 405.354	Waiver of adjustment or recovery
Section 405.355	Principles applied in waiver of adjustment or recovery
Section 405.356	Notice of right to waiver consideration
Section 405.357	When waiver of adjustment or recovery may be applied
Section 405.358	Liability of certifying or disbursing officer
Section 405.359	Definitions
Section 405.370	Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services
Section 405.371	Proceeding for suspension of payment
Section 405.372	Proceeding for offset or recoupment
Section 405.373	Opportunity for rebuttal
Section 405.374	Time limits for, and notification of, administrative determination after receipt of rebuttal statement
Section 405.375	Suspension and termination of collection action and compromise of claims for overpayment
Section 405.376	Withholding Medicare payments to recover Medicaid overpayments
Section 405.377	Interest charges on overpayment and underpayments to providers, suppliers, and other entities
Section 405.378	Limitation on recoupment of provider and supplier overpayments
Section 405.379	Collection of past-due amounts on scholarship and loan programs
Section 405.380	Definitions
Section 405.400	General rules
Section 405.405	Conditions for properly opting-out of Medicare
Section 405.410	Requirements of the private contract
Section 405.415	Requirements of the opt-out affidavit
Section 405.420	Effects of opting-out of Medicare
Section 405.425	Failure to properly opt-out
Section 405.430	Failure to maintain opt-out
Section 405.435	Emergency and urgent care services
Section 405.440	Renewal and early termination of opt-out
Section 405.445	Appeals
Section 405.450	Application to Medicare Advantage contracts
Section 405.455	Basis
Section 405.500	Determination of reasonable charges
Section 405.501	Criteria for determining reasonable charges
Section 405.502	Determining customary charges
Section 405.503	Determining prevailing charges
Section 405.504	Determination of locality
Section 405.505	Charges higher than customary or prevailing charges or lowest charge levels
Section 405.506	Illustrations of the application of the criteria for determining reasonable charges
Section 405.507	Determination of comparable circumstances; limitation
Section 405.508	Determining the inflation-indexed charge
Section 405.509	Reasonable charges for medical services, supplies, and equipment
Section 405.511	Carriers' procedural terminology and coding systems
Section 405.512	Reimbursement for clinical laboratory services billed by physicians
Section 405.515	Payment for drugs and biologicals that are not paid on a cost or prospective payment basis
Section 405.517	Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services
Section 405.520	Limitation on payment for screening mammography services
Section 405.534	Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before
Section 405.535	Appeals of CMS or a CMS contractor
Section 405.800	Appeals rights
Section 405.803	Impact of reversal of contractor determinations on claims processing
Section 405.806	Reinstatement of provider or supplier billing privileges following corrective action
Section 405.809	Effective date for DMEPOS supplier's billing privileges
Section 405.812	Submission of claims
Section 405.815	Deadline for processing provider enrollment initial determinations
Section 405.818	Basis and scope
Section 405.900	Definitions
Section 405.902	Medicare initial determinations, redeterminations and appeals: General description
Section 405.904	Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews
Section 405.906	Medicaid State agencies
Section 405.908	Appointed representatives
Section 405.910	Assignment of appeal rights
Section 405.912	Initial determinations
Section 405.920	Notice of initial determination
Section 405.921	Time frame for processing initial determinations
Section 405.922	Actions that are initial determinations
Section 405.924	Decisions of utilization review committees
Section 405.925	Actions that are not initial determinations
Section 405.926	Initial determinations subject to the reopenings process
Section 405.927	Effect of the initial determination
Section 405.928	Right to a redetermination
Section 405.940	Time frame for filing a request for a redetermination
Section 405.942	Place and method of filing a request for a redetermination
Section 405.944	Evidence to be submitted with the redetermination request
Section 405.946	Notice to the beneficiary of applicable plan's request for a redetermination
Section 405.947	Conduct of a redetermination
Section 405.948	Time frame for making a redetermination
Section 405.950	Withdrawal or dismissal of a request for a redetermination
Section 405.952	Redetermination
Section 405.954	Notice of a redetermination
Section 405.956	Effect of a redetermination
Section 405.958	Right to a reconsideration
Section 405.960	Timeframe for filing a request for a reconsideration
Section 405.962	Place and method of filing a request for a reconsideration
Section 405.964	Evidence to be submitted with the reconsideration request
Section 405.966	Conduct of a reconsideration
Section 405.968	Timeframe for making a reconsideration
Section 405.970	Withdrawal or dismissal of a request for a reconsideration
Section 405.972	Reconsideration
Section 405.974	Notice of a reconsideration
Section 405.976	Effect of a reconsideration
Section 405.978	Reopening of initial determinations, redeterminations, reconsiderations, hearings, and reviews
Section 405.980	Notice of a revised determination or decision
Section 405.982	Effect of a revised determination or decision
Section 405.984	Good cause for reopening
Section 405.986	Expedited access to judicial review
Section 405.990	Hearing before an ALJ: General rule
Section 405.1000	Right to an ALJ hearing
Section 405.1002	Right to ALJ review of QIC notice of dismissal
Section 405.1004	Amount in controversy required to request an ALJ hearing and judicial review
Section 405.1006	Parties to an ALJ hearing
Section 405.1008	When CMS or its contractors may participate in an ALJ hearing
Section 405.1010	When CMS or its contractors may be a party to a hearing
Section 405.1012	Request for an ALJ hearing
Section 405.1014	Time frames for deciding an appeal before an ALJ
Section 405.1016	Submitting evidence before the ALJ hearing
Section 405.1018	Time and place for a hearing before an ALJ
Section 405.1020	Notice of a hearing before an ALJ
Section 405.1022	Objections to the issues
Section 405.1024	Disqualification of the ALJ
Section 405.1026	Prehearing case review of evidence submitted to the ALJ
Section 405.1028	ALJ hearing procedures
Section 405.1030	Issues before an ALJ
Section 405.1032	When an ALJ may remand a case to the QIC
Section 405.1034	Description of an ALJ hearing process
Section 405.1036	Discovery
Section 405.1037	Deciding a case without a hearing before an ALJ
Section 405.1038	Prehearing and posthearing conferences
Section 405.1040	The administrative record
Section 405.1042	Consolidated hearing before an ALJ
Section 405.1044	Notice of an ALJ decision
Section 405.1046	The effect of an ALJ's decision
Section 405.1048	Removal of a hearing request from an ALJ to the MAC
Section 405.1050	Dismissal of a request for a hearing before an ALJ
Section 405.1052	Effect of dismissal of a request for a hearing before an ALJ
Section 405.1054	Applicability of national coverage determinations (NCDs)
Section 405.1060	Applicability of local coverage determinations and other policies not binding on the ALJ and MAC
Section 405.1062	Applicability of laws, regulations and CMS Rulings
Section 405.1063	ALJ decisions involving statistical samples
Section 405.1064	Medicare Appeals Council review: General
Section 405.1100	Request for MAC review when ALJ issues decision or dismissal
Section 405.1102	Request for MAC review when an ALJ does not issue a decision timely
Section 405.1104	Where a request for review or escalation may be filed
Section 405.1106	MAC actions when request for review or escalation is filed
Section 405.1108	MAC reviews on its own motion
Section 405.1110	Content of request for review
Section 405.1112	Dismissal of request for review
Section 405.1114	Effect of dismissal of request for MAC review or request for hearing
Section 405.1116	Obtaining evidence from the MAC
Section 405.1118	Filing briefs with the MAC
Section 405.1120	What evidence may be submitted to the MAC
Section 405.1122	Oral argument
Section 405.1124	Case remanded by the MAC
Section 405.1126	Action of the MAC
Section 405.1128	Effect of the MAC's decision
Section 405.1130	Request for escalation to Federal court
Section 405.1132	Extension of time to file action in Federal district court
Section 405.1134	Judicial review
Section 405.1136	Case remanded by a Federal district court
Section 405.1138	MAC review of ALJ decision in a case remanded by a Federal district court
Section 405.1140	Notifying beneficiaries of provider service terminations
Section 405.1200	Expedited determination procedures
Section 405.1202	Expedited reconsiderations
Section 405.1204	Notifying beneficiaries of hospital discharge appeal rights
Section 405.1205	Expedited determination procedures for inpatient hospital care
Section 405.1206	Hospital requests expedited QIO review
Section 405.1208	Introduction
Section 405.1801	Contractor determination and notice of amount of program reimbursement
Section 405.1803	Matters not subject to administrative and judicial review under prospective payment
Section 405.1804	Parties to contractor determination
Section 405.1805	Effect of contractor determination
Section 405.1807	Contractor hearing procedures
Section 405.1809	Right to contractor hearing; contents of, and adding issues to, hearing request
Section 405.1811	Good cause extension of time limit for requesting a contractor hearing
Section 405.1813	Contractor hearing officer jurisdiction
Section 405.1814	Parties to proceedings before the contractor hearing officer(s)
Section 405.1815	Hearing officer or panel of hearing officers authorized to conduct contractor hearing; disqualification of officers
Section 405.1817	Conduct of contractor hearing
Section 405.1819	Prehearing discovery and other proceedings prior to the contractor hearing
Section 405.1821	Evidence at contractor hearing
Section 405.1823	Witnesses at contractor hearing
Section 405.1825	Record of proceedings before the contractor hearing officer(s)
Section 405.1827	Scope of authority of contractor hearing officer(s)
Section 405.1829	Contractor hearing decision
Section 405.1831	Effect of contractor hearing decision
Section 405.1833	CMS reviewing official procedure
Section 405.1834	Right to Board hearing; contents of, and adding issues to, hearing request
Section 405.1835	Good cause extension of time limit for requesting a Board hearing
Section 405.1836	Group appeals
Section 405.1837	Amount in controversy
Section 405.1839	Board jurisdiction
Section 405.1840	Expedited judicial review
Section 405.1842	Parties to proceedings in a Board appeal
Section 405.1843	Composition of Board; hearings, decisions, and remands
Section 405.1845	Disqualification of Board members
Section 405.1847	Establishment of time and place of hearing by the Board
Section 405.1849	Conduct of Board hearing
Section 405.1851	Board proceedings prior to any hearing; discovery
Section 405.1853	Evidence at Board hearing
Section 405.1855	Subpoenas
Section 405.1857	Witnesses
Section 405.1859	Oral argument and written allegations
Section 405.1861	Administrative policy at issue
Section 405.1863	Record of administrative proceedings
Section 405.1865	Scope of Board's legal authority
Section 405.1867	Board actions in response to failure to follow Board rules
Section 405.1868	Scope of Board's authority in a hearing decision
Section 405.1869	Board hearing decision
Section 405.1871	Administrator review
Section 405.1875	Judicial review
Section 405.1877	Appointment of representative
Section 405.1881	Authority of representative
Section 405.1883	Reopening a contractor determination or reviewing entity decision
Section 405.1885	Notice of reopening; effect of reopening
Section 405.1887	Effect of a revision; issue-specific nature of appeals of revised determinations and decisions
Section 405.1889	Definitions
Section 405.2102	Designation of ESRD networks
Section 405.2110	ESRD network organizations
Section 405.2112	Medical review board
Section 405.2113	Basis
Section 405.2400	Scope and definitions
Section 405.2401	Rural health clinic basic requirements
Section 405.2402	Rural health clinic content and terms of the agreement with the Secretary
Section 405.2403	Termination of rural health clinic agreements
Section 405.2404	Application of Part B deductible and coinsurance
Section 405.2410	Scope of benefits
Section 405.2411	Physicians' services
Section 405.2412	Services and supplies incident to a physician's services
Section 405.2413	Nurse practitioner, physician assistant, and certified nurse midwife services
Section 405.2414	Services and supplies incident to nurse practitioner, physician assistant, or certified nurse-midwife services
Section 405.2415	Visiting nurse services
Section 405.2416	Visiting nurse services: Determination of shortage of agencies
Section 405.2417	Basic requirements
Section 405.2430	Content and terms of the agreement
Section 405.2434	Termination of agreement
Section 405.2436	Conditions for reinstatement after termination by CMS
Section 405.2440	Notice to the public
Section 405.2442	Change of ownership
Section 405.2444	Scope of services
Section 405.2446	Preventive primary services
Section 405.2448	Preventive services
Section 405.2449	Clinical psychologist and clinical social worker services
Section 405.2450	Services and supplies incident to clinical psychologist and clinical social worker services
Section 405.2452	Applicability of general payment exclusions
Section 405.2460	Payment for RHC and FQHC services
Section 405.2462	What constitutes a visit
Section 405.2463	Payment rate
Section 405.2464	Annual reconciliation
Section 405.2466	Requirements of the FQHC PPS
Section 405.2467	Allowable costs
Section 405.2468	FQHC supplemental payments
Section 405.2469	Reports and maintenance of records
Section 405.2470	Beneficiary appeals
Section 405.2472	Statutory basis