About GPO   |   Newsroom/Media   |   Congressional Relations   |   Inspector General   |   Careers   |   Contact   |   askGPO   |   Help  
 
Home   |   Customers   |   Vendors   |   Libraries  

The Electronic Code of Federal Regulations (e-CFR) is a regularly updated, unofficial editorial compilation of CFR material and Federal Register amendments produced by the National Archives and Records Administration's Office of the Federal Register (OFR) and the Government Printing Office.

Parallel Table of Authorities and Rules for the Code of Federal Regulations and the United States Code
Text | PDF

Find, review, and submit comments on Federal rules that are open for comment and published in the Federal Register using Regulations.gov.

Purchase individual CFR titles from the U.S. Government Online Bookstore.

Find issues of the CFR (including issues prior to 1996) at a local Federal depository library.

[1]
 
 

Electronic Code of Federal Regulations

blue pill

e-CFR Data is current as of October 29, 2014

Title 42Chapter IVSubchapter BPart 405


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

rule

Subpart A—[RESERVED]

rule

Subpart B—MEDICAL SERVICES COVERAGE DECISIONS THAT RELATE TO HEALTH CARE TECHNOLOGY

§405.201
Scope of subpart and definitions.
§405.203
FDA categorization of investigational devices.
§405.205
Coverage of a non-experimental/investigational (Category B) device.
§405.207
Services related to a noncovered device.
§405.209
Payment for a non-experimental/investigational (Category B) device.
§405.211
Procedures for Medicare contractors in making coverage decisions for a non-experimental/investigational (Category B) device.
§405.212
§405.213
Re-evaluation of a device categorization.
§405.215
Confidential commercial and trade secret information.
rule

Subpart C—SUSPENSION OF PAYMENT, RECOVERY OF OVERPAYMENTS, AND REPAYMENT OF SCHOLARSHIPS AND LOANS

General Provisions

§405.301
Scope of subpart.

Liability for Payments To Providers or Suppliers and Handling of Incorrect Payments

§405.350
Individual's liability for payments made to providers and other persons for items and services furnished the individual.
§405.351
Incorrect payments for which the individual is not liable.
§405.352
Adjustment of title XVIII incorrect payments.
§405.353
Certification of amount that will be adjusted against individual title II or railroad retirement benefits.
§405.354
Procedures for adjustment or recovery—title II beneficiary.
§405.355
Waiver of adjustment or recovery.
§405.356
Principles applied in waiver of adjustment or recovery.
§405.357
Notice of right to waiver consideration.
§405.358
When waiver of adjustment or recovery may be applied.
§405.359
Liability of certifying or disbursing officer.

Suspension and Recoupment of Payment to Providers and Suppliers and Collection and Compromise of Overpayments

§405.370
Definitions.
§405.371
Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
§405.372
Proceeding for suspension of payment.
§405.373
Proceeding for offset or recoupment.
§405.374
Opportunity for rebuttal.
§405.375
Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
§405.376
Suspension and termination of collection action and compromise of claims for overpayment.
§405.377
Withholding Medicare payments to recover Medicaid overpayments.
§405.378
Interest charges on overpayment and underpayments to providers, suppliers, and other entities.
§405.379
Limitation on recoupment of provider and supplier overpayments.

Repayment of Scholarships and Loans

§405.380
Collection of past-due amounts on scholarship and loan programs.
rule

Subpart D—PRIVATE CONTRACTS

§405.400
Definitions.
§405.405
General rules.
§405.410
Conditions for properly opting-out of Medicare.
§405.415
Requirements of the private contract.
§405.420
Requirements of the opt-out affidavit.
§405.425
Effects of opting-out of Medicare.
§405.430
Failure to properly opt-out.
§405.435
Failure to maintain opt-out.
§405.440
Emergency and urgent care services.
§405.445
Renewal and early termination of opt-out.
§405.450
Appeals.
§405.455
Application to Medicare+Choice contracts.
rule

Subpart E—CRITERIA FOR DETERMINING REASONABLE CHARGES

§405.500
Basis.
§405.501
Determination of reasonable charges.
§405.502
Criteria for determining reasonable charges.
§405.503
Determining customary charges.
§405.504
Determining prevailing charges.
§405.505
Determination of locality.
§405.506
Charges higher than customary or prevailing charges or lowest charge levels.
§405.507
Illustrations of the application of the criteria for determining reasonable charges.
§405.508
Determination of comparable circumstances; limitation.
§405.509
Determining the inflation-indexed charge.
§405.511
Reasonable charges for medical services, supplies, and equipment.
§405.512
Carriers' procedural terminology and coding systems.
§405.515
Reimbursement for clinical laboratory services billed by physicians.
§405.517
Payment for drugs and biologicals that are not paid on a cost or prospective payment basis.
§405.520
Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services furnished incident to their professional services.
§405.534
Limitation on payment for screening mammography services.
§405.535
Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002.
rule

Subparts F-G [Reserved]

rule

Subpart H—APPEALS UNDER THE MEDICARE PART B PROGRAM

§405.800
Appeals of CMS or a CMS contractor.
§405.803
Appeals rights.
§405.806
Impact of reversal of contractor determinations on claims processing.
§405.809
Reinstatement of provider or supplier billing privileges following corrective action.
§405.812
Effective date for DMEPOS supplier's billing privileges.
§405.815
Submission of claims.
§405.818
Deadline for processing provider enrollment initial determinations.
rule

Subpart I—DETERMINATIONS, REDETERMINATIONS, RECONSIDERATIONS, AND APPEALS UNDER ORIGINAL MEDICARE (PART A AND PART B)

§405.900
Basis and scope.
§405.902
Definitions.
§405.904
Medicare initial determinations, redeterminations and appeals: General description.
§405.906
Parties to the initial determinations, redeterminations, reconsiderations, hearings and reviews.
§405.908
Medicaid State agencies.
§405.910
Appointed representatives.
§405.912
Assignment of appeal rights.

Initial Determinations

§405.920
Initial determinations.
§405.921
Notice of initial determination.
§405.922
Time frame for processing initial determinations.
§405.924
Actions that are initial determinations.
§405.925
Decisions of utilization review committees.
§405.926
Actions that are not initial determinations.
§405.927
Initial determinations subject to the reopenings process.
§405.928
Effect of the initial determination.

Redeterminations

§405.940
Right to a redetermination.
§405.942
Time frame for filing a request for a redetermination.
§405.944
Place and method of filing a request for a redetermination.
§405.946
Evidence to be submitted with the redetermination request.
§405.948
Conduct of a redetermination.
§405.950
Time frame for making a redetermination.
§405.952
Withdrawal or dismissal of a request for a redetermination.
§405.954
Redetermination.
§405.956
Notice of a redetermination.
§405.958
Effect of a redetermination.

Reconsideration

§405.960
Right to a reconsideration.
§405.962
Timeframe for filing a request for a reconsideration.
§405.964
Place and method of filing a request for a reconsideration.
§405.966
Evidence to be submitted with the reconsideration request.
§405.968
Conduct of a reconsideration.
§405.970
Timeframe for making a reconsideration.
§405.972
Withdrawal or dismissal of a request for a reconsideration.
§405.974
Reconsideration.
§405.976
Notice of a reconsideration.
§405.978
Effect of a reconsideration.

Reopenings

§405.980
Reopenings of initial determinations, redeterminations, and reconsiderations, hearings and reviews.
§405.982
Notice of a revised determination or decision.
§405.984
Effect of a revised determination or decision.
§405.986
Good cause for reopening.

Expedited Access to Judicial Review

§405.990
Expedited access to judicial review.

ALJ Hearings

§405.1000
Hearing before an ALJ: General rule.
§405.1002
Right to an ALJ hearing.
§405.1004
Right to ALJ review of QIC notice of dismissal.
§405.1006
Amount in controversy required to request an ALJ hearing and judicial review.
§405.1008
Parties to an ALJ hearing.
§405.1010
When CMS or its contractors may participate in an ALJ hearing.
§405.1012
When CMS or its contractors may be a party to a hearing.
§405.1014
Request for an ALJ hearing.
§405.1016
Time frames for deciding an appeal before an ALJ.
§405.1018
Submitting evidence before the ALJ hearing.
§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.
§405.1028
Prehearing case review of evidence submitted to the ALJ.
§405.1030
ALJ hearing procedures.
§405.1032
Issues before an ALJ.
§405.1034
When an ALJ may remand a case to 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 hearing before an ALJ.
§405.1046
Notice of an ALJ decision.
§405.1048
The effect of an ALJ's decision.
§405.1050
Removal of a hearing request from an ALJ to the MAC.
§405.1052
Dismissal of a request for a hearing before an ALJ.
§405.1054
Effect of dismissal of a request for a hearing before an ALJ.

Applicability of Medicare Coverage Policies

§405.1060
Applicability of national coverage determinations (NCDs).
§405.1062
Applicability of local coverage determinations and other policies not binding on the ALJ and MAC.
§405.1063
Applicability of laws, regulations and CMS Rulings.
§405.1064
ALJ decisions involving statistical samples.

Medicare Appeals Council Review

§405.1100
Medicare Appeals Council review: General.
§405.1102
Request for MAC review when ALJ issues decision or dismissal.
§405.1104
Request for MAC review when an ALJ does not issue a decision timely.
§405.1106
Where a request for review or escalation may be filed.
§405.1108
MAC actions when request for review or escalation is filed.
§405.1110
MAC 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 MAC review or request for hearing.
§405.1118
Obtaining evidence from the MAC.
§405.1120
Filing briefs with the MAC.
§405.1122
What evidence may be submitted to the MAC.
§405.1124
Oral argument.
§405.1126
Case remanded by the MAC.
§405.1128
Action of the MAC.
§405.1130
Effect of the MAC'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
MAC review of ALJ decision in a case remanded by a Federal district court.
rule

Subpart J—EXPEDITED DETERMINATIONS AND RECONSIDERATIONS OF PROVIDER SERVICE TERMINATIONS, AND PROCEDURES FOR INPATIENT HOSPITAL DISCHARGES

§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.
rule

Subparts K-Q [Reserved]

rule

Subpart R—PROVIDER REIMBURSEMENT DETERMINATIONS AND APPEALS

§405.1801
Introduction.
§405.1803
Contractor determination and notice of amount of program reimbursement.
§405.1804
Matters not subject to administrative and judicial review under prospective payment.
§405.1805
Parties to contractor determination.
§405.1807
Effect of contractor determination.
§405.1809
Contractor hearing procedures.
§405.1811
Right to contractor hearing; contents of, and adding issues to, hearing request.
§405.1813
Good cause extension of time limit for requesting a contractor hearing.
§405.1814
Contractor hearing officer jurisdiction.
§405.1815
Parties to proceedings before the contractor hearing officer(s).
§405.1817
Hearing officer or panel of hearing officers authorized to conduct contractor hearing; disqualification of officers.
§405.1819
Conduct of contractor hearing.
§405.1821
Prehearing discovery and other proceedings prior to the contractor hearing.
§405.1823
Evidence at contractor hearing.
§405.1825
Witnesses at contractor hearing.
§405.1827
Record of proceedings before the contractor hearing officer(s).
§405.1829
Scope of authority of contractor hearing officer(s).
§405.1831
Contractor hearing decision.
§405.1833
Effect of contractor hearing decision.
§405.1834
CMS reviewing official procedure.
§405.1835
Right to Board hearing; contents of, and adding issues to, hearing request.
§405.1836
Good cause extension of time limit for requesting a Board hearing.
§405.1837
Group appeals.
§405.1839
Amount in controversy.
§405.1840
Board jurisdiction.
§405.1842
Expedited judicial review.
§405.1843
Parties to proceedings in a Board appeal.
§405.1845
Composition of Board; hearings, decisions, and remands.
§405.1847
Disqualification of Board members.
§405.1849
Establishment of time and place of hearing by the Board.
§405.1851
Conduct of Board hearing.
§405.1853
Board proceedings prior to any hearing; discovery.
§405.1855
Evidence at Board hearing.
§405.1857
Subpoenas.
§405.1859
Witnesses.
§405.1861
Oral argument and written allegations.
§405.1863
Administrative policy at issue.
§405.1865
Record of administrative proceedings.
§405.1867
Scope of Board's legal authority.
§405.1868
Board actions in response to failure to follow Board rules.
§405.1869
Scope of Board's authority in a hearing decision.
§405.1871
Board hearing decision.
§405.1873
[Reserved]
§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.
rule

Subparts S-T [Reserved]

rule

Subpart U—CONDITIONS FOR COVERAGE OF SUPPLIERS OF END-STAGE RENAL DISEASE (ESRD) SERVICES

§§405.2100-405.2101
[Reserved]
§405.2102
Definitions.
§405.2110
Designation of ESRD networks.
§405.2111
[Reserved]
§405.2112
ESRD network organizations.
§405.2113
Medical review board.
§405.2114
[Reserved]
§§405.2131-405.2184
[Reserved]
rule

Subparts V-W [Reserved]

rule

Subpart X—RURAL HEALTH CLINIC AND FEDERALLY QUALIFIED HEALTH CENTER SERVICES

§405.2400
Basis.
§405.2401
Scope and definitions.
§405.2402
Rural health clinic basic requirements.
§405.2403
Rural health clinic content and terms of the agreement with the Secretary.
§405.2404
Termination of rural health clinic agreements.
§405.2410
Application of Part B deductible and coinsurance.
§405.2411
Scope of benefits.
§405.2412
Physicians' services.
§405.2413
Services and supplies incident to a physician's services.
§405.2414
Nurse practitioner, physician assistant, and certified nurse midwife services.
§405.2415
Services and supplies incident to nurse practitioner, physician assistant, certified nurse midwife, clinical psychologist, or clinical social worker services.
§405.2416
Visiting nurse services.
§405.2417
Visiting nurse services: Determination of shortage of agencies.

Federally Qualified Health Center Services

§405.2430
Basic requirements.
§405.2434
Content and terms of the agreement.
§405.2436
Termination of agreement.
§405.2440
Conditions for reinstatement after termination by CMS.
§405.2442
Notice to the public.
§405.2444
Change of ownership.
§405.2446
Scope of services.
§405.2448
Preventive primary services.
§405.2449
Preventive services.
§405.2450
Clinical psychologist and clinical social worker services.
§405.2452
Services and supplies incident to clinical psychologist and clinical social worker services.

Payment for Rural Health Clinic and Federally Qualified Health Center Services

§405.2460
Applicability of general payment exclusions.
§405.2462
Payment for RHC and FQHC services.
§405.2463
What constitutes a visit.
§405.2464
Payment rate.
§405.2466
Annual reconciliation.
§405.2467
Requirements of the FQHC PPS.
§405.2468
Allowable costs.
§405.2469
FQHC supplemental payments.
§405.2470
Reports and maintenance of records.
§405.2472
Beneficiary appeals.


For questions or comments regarding e-CFR editorial content, features, or design, email ecfr@nara.gov.
For questions concerning e-CFR programming and delivery issues, email webteam@gpo.gov.