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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter B - Medicare Program |
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Part 405 - Federal Health Insurance for the Aged and Disabled |
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Subpart I - Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B) |
Subpart I - Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)
| § 405.900 - Basis and scope. |
| § 405.902 - Definitions. |
| § 405.903 - xxx |
| § 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. |
| 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 or attorney adjudicator and Council. |
| § 405.1063 - Applicability of laws, regulations, CMS Rulings, and precedential decisions. |
| § 405.1064 - ALJ decisions involving statistical samples. |
| Retrospective Appeals for Changes in Patient Status That Resulted in Denial of Part A Coverage for Hospital Services |
| § 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. |
| 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. |
| § 405.929 - Post-payment review. |
| § 405.930 - Failure to respond to additional documentation request. |
| §§ 405.929--405.930 - xxx |
| Reopenings |
| § 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. |
| Expedited Access to Judicial Review |
| § 405.990 - Expedited access to judicial review. |
| 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. |
| § 405.947 - 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. |
| 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 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. |
| ALJ Hearings |
| § 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 - xxx |
| § 405.1058 - xxx |
| Medicare Appeals Council Review |
| § 405.1100 - Medicare Appeals Council review: General. |
| § 405.1102 - Request for Council review when ALJ or attorney adjudicator 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 - 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. |