Title 42

CHAPTER IV SUBCHAP B

Subchapter B - Medicare Program

42:2.0.1.2.5PART 405
PART 405 - FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
42:2.0.1.2.5.1SUBPART A
Subpart A [Reserved]
42:2.0.1.2.5.2SUBPART B
Subpart B - Medical Services Coverage Decisions That Relate to Health Care Technology
42:2.0.1.2.5.2.21.1SECTION 405.201
     405.201 Scope of subpart and definitions.
42:2.0.1.2.5.2.21.2SECTION 405.203
     405.203 FDA categorization of investigational devices.
42:2.0.1.2.5.2.21.3SECTION 405.205
     405.205 Coverage of a Category B (Nonexperimental/investigational) device.
42:2.0.1.2.5.2.21.4SECTION 405.207
     405.207 Services related to a noncovered device.
42:2.0.1.2.5.2.21.5SECTION 405.209
     405.209 Payment for a Category B (Nonexperimental/investigational) device.
42:2.0.1.2.5.2.21.6SECTION 405.211
     405.211 Coverage of items and services in FDA-approved IDE studies.
42:2.0.1.2.5.2.21.7SECTION 405.212
     405.212 Medicare Coverage IDE study criteria.
42:2.0.1.2.5.2.21.8SECTION 405.213
     405.213 Re-evaluation of a device categorization.
42:2.0.1.2.5.2.21.9SECTION 405.215
     405.215 Confidential commercial and trade secret information.
42:2.0.1.2.5.3SUBPART C
Subpart C - Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans
42:2.0.1.2.5.3.21SUBJGRP 21
  General Provisions
42:2.0.1.2.5.3.21.1SECTION 405.301
     405.301 Scope of subpart.
42:2.0.1.2.5.3.22SUBJGRP 22
  Liability for Payments To Providers or Suppliers and Handling of Incorrect Payments
42:2.0.1.2.5.3.22.2SECTION 405.350
     405.350 Individual's liability for payments made to providers and other persons for items and services furnished the individual.
42:2.0.1.2.5.3.22.3SECTION 405.351
     405.351 Incorrect payments for which the individual is not liable.
42:2.0.1.2.5.3.22.4SECTION 405.352
     405.352 Adjustment of title XVIII incorrect payments.
42:2.0.1.2.5.3.22.5SECTION 405.353
     405.353 Certification of amount that will be adjusted against individual title II or railroad retirement benefits.
42:2.0.1.2.5.3.22.6SECTION 405.354
     405.354 Procedures for adjustment or recovery - title II beneficiary.
42:2.0.1.2.5.3.22.7SECTION 405.355
     405.355 Waiver of adjustment or recovery.
42:2.0.1.2.5.3.22.8SECTION 405.356
     405.356 Principles applied in waiver of adjustment or recovery.
42:2.0.1.2.5.3.22.9SECTION 405.357
     405.357 Notice of right to waiver consideration.
42:2.0.1.2.5.3.22.10SECTION 405.358
     405.358 When waiver of adjustment or recovery may be applied.
42:2.0.1.2.5.3.22.11SECTION 405.359
     405.359 Liability of certifying or disbursing officer.
42:2.0.1.2.5.3.23SUBJGRP 23
  Suspension and Recoupment of Payment to Providers and Suppliers and Collection and Compromise of Overpayments
42:2.0.1.2.5.3.23.12SECTION 405.370
     405.370 Definitions.
42:2.0.1.2.5.3.23.13SECTION 405.371
     405.371 Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
42:2.0.1.2.5.3.23.14SECTION 405.372
     405.372 Proceeding for suspension of payment.
42:2.0.1.2.5.3.23.15SECTION 405.373
     405.373 Proceeding for offset or recoupment.
42:2.0.1.2.5.3.23.16SECTION 405.374
     405.374 Opportunity for rebuttal.
42:2.0.1.2.5.3.23.17SECTION 405.375
     405.375 Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
42:2.0.1.2.5.3.23.18SECTION 405.376
     405.376 Suspension and termination of collection action and compromise of claims for overpayment.
42:2.0.1.2.5.3.23.19SECTION 405.377
     405.377 Withholding Medicare payments to recover Medicaid overpayments.
42:2.0.1.2.5.3.23.20SECTION 405.378
     405.378 Interest charges on overpayment and underpayments to providers, suppliers, and other entities.
42:2.0.1.2.5.3.23.21SECTION 405.379
     405.379 Limitation on recoupment of provider and supplier overpayments.
42:2.0.1.2.5.3.24SUBJGRP 24
  Repayment of Scholarships and Loans
42:2.0.1.2.5.3.24.22SECTION 405.380
     405.380 Collection of past-due amounts on scholarship and loan programs.
42:2.0.1.2.5.4SUBPART D
Subpart D - Private Contracts
42:2.0.1.2.5.4.25.1SECTION 405.400
     405.400 Definitions.
42:2.0.1.2.5.4.25.2SECTION 405.405
     405.405 General rules.
42:2.0.1.2.5.4.25.3SECTION 405.410
     405.410 Conditions for properly opting-out of Medicare.
42:2.0.1.2.5.4.25.4SECTION 405.415
     405.415 Requirements of the private contract.
42:2.0.1.2.5.4.25.5SECTION 405.420
     405.420 Requirements of the opt-out affidavit.
42:2.0.1.2.5.4.25.6SECTION 405.425
     405.425 Effects of opting-out of Medicare.
42:2.0.1.2.5.4.25.7SECTION 405.430
     405.430 Failure to properly opt-out.
42:2.0.1.2.5.4.25.8SECTION 405.435
     405.435 Failure to maintain opt-out.
42:2.0.1.2.5.4.25.9SECTION 405.440
     405.440 Emergency and urgent care services.
42:2.0.1.2.5.4.25.10SECTION 405.445
     405.445 Cancellation of opt-out and early termination of opt-out.
42:2.0.1.2.5.4.25.11SECTION 405.450
     405.450 Appeals.
42:2.0.1.2.5.4.25.12SECTION 405.455
     405.455 Application to Medicare Advantage contracts.
42:2.0.1.2.5.5SUBPART E
Subpart E - Criteria for Determining Reasonable Charges
42:2.0.1.2.5.5.25.1SECTION 405.500
     405.500 Basis.
42:2.0.1.2.5.5.25.2SECTION 405.501
     405.501 Determination of reasonable charges.
42:2.0.1.2.5.5.25.3SECTION 405.502
     405.502 Criteria for determining reasonable charges.
42:2.0.1.2.5.5.25.4SECTION 405.503
     405.503 Determining customary charges.
42:2.0.1.2.5.5.25.5SECTION 405.504
     405.504 Determining prevailing charges.
42:2.0.1.2.5.5.25.6SECTION 405.505
     405.505 Determination of locality.
42:2.0.1.2.5.5.25.7SECTION 405.506
     405.506 Charges higher than customary or prevailing charges or lowest charge levels.
42:2.0.1.2.5.5.25.8SECTION 405.507
     405.507 Illustrations of the application of the criteria for determining reasonable charges.
42:2.0.1.2.5.5.25.9SECTION 405.508
     405.508 Determination of comparable circumstances; limitation.
42:2.0.1.2.5.5.25.10SECTION 405.509
     405.509 Determining the inflation-indexed charge.
42:2.0.1.2.5.5.25.11SECTION 405.511
     405.511 Reasonable charges for medical services, supplies, and equipment.
42:2.0.1.2.5.5.25.12SECTION 405.512
     405.512 Carriers' procedural terminology and coding systems.
42:2.0.1.2.5.5.25.13SECTION 405.515
     405.515 Reimbursement for clinical laboratory services billed by physicians.
42:2.0.1.2.5.5.25.14SECTION 405.517
     405.517 Payment for drugs and biologicals that are not paid on a cost or prospective payment basis.
42:2.0.1.2.5.5.25.15SECTION 405.520
     405.520 Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services furnished incident to their professional services.
42:2.0.1.2.5.5.25.16SECTION 405.534
     405.534 Limitation on payment for screening mammography services.
42:2.0.1.2.5.5.25.17SECTION 405.535
     405.535 Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002.
42:2.0.1.2.5.6SUBPART F
Subparts F-G [Reserved]
42:2.0.1.2.5.7SUBPART H
Subpart H - Appeals Under the Medicare Part B Program
42:2.0.1.2.5.7.25.1SECTION 405.800
     405.800 Appeals of CMS or a CMS contractor.
42:2.0.1.2.5.7.25.2SECTION 405.803
     405.803 Appeals rights.
42:2.0.1.2.5.7.25.3SECTION 405.806
     405.806 Impact of reversal of contractor determinations on claims processing.
42:2.0.1.2.5.7.25.4SECTION 405.809
     405.809 Reinstatement of provider or supplier billing privileges following corrective action.
42:2.0.1.2.5.7.25.5SECTION 405.812
     405.812 Effective date for DMEPOS supplier's billing privileges.
42:2.0.1.2.5.7.25.6SECTION 405.815
     405.815 Submission of claims.
42:2.0.1.2.5.7.25.7SECTION 405.818
     405.818 Deadline for processing provider enrollment initial determinations.
42:2.0.1.2.5.8SUBPART I
Subpart I - Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)
42:2.0.1.2.5.8.25SUBJGRP 25
  Initial Determinations
42:2.0.1.2.5.8.25.1SECTION 405.900
     405.900 Basis and scope.
42:2.0.1.2.5.8.25.2SECTION 405.902
     405.902 Definitions.
42:2.0.1.2.5.8.25.3SECTION 405.904
     405.904 Medicare initial determinations, redeterminations and appeals: General description.
42:2.0.1.2.5.8.25.4SECTION 405.906
     405.906 Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.
42:2.0.1.2.5.8.25.5SECTION 405.908
     405.908 Medicaid State agencies.
42:2.0.1.2.5.8.25.6SECTION 405.910
     405.910 Appointed representatives.
42:2.0.1.2.5.8.25.7SECTION 405.912
     405.912 Assignment of appeal rights.
42:2.0.1.2.5.8.25.8SECTION 405.920
     405.920 Initial determinations.
42:2.0.1.2.5.8.25.9SECTION 405.921
     405.921 Notice of initial determination.
42:2.0.1.2.5.8.25.10SECTION 405.922
     405.922 Time frame for processing initial determinations.
42:2.0.1.2.5.8.25.11SECTION 405.924
     405.924 Actions that are initial determinations.
42:2.0.1.2.5.8.25.12SECTION 405.925
     405.925 Decisions of utilization review committees.
42:2.0.1.2.5.8.25.13SECTION 405.926
     405.926 Actions that are not initial determinations.
42:2.0.1.2.5.8.25.14SECTION 405.927
     405.927 Initial determinations subject to the reopenings process.
42:2.0.1.2.5.8.25.15SECTION 405.928
     405.928 Effect of the initial determination.
42:2.0.1.2.5.8.26SUBJGRP 26
  Redeterminations
42:2.0.1.2.5.8.26.16SECTION 405.940
     405.940 Right to a redetermination.
42:2.0.1.2.5.8.26.17SECTION 405.942
     405.942 Time frame for filing a request for a redetermination.
42:2.0.1.2.5.8.26.18SECTION 405.944
     405.944 Place and method of filing a request for a redetermination.
42:2.0.1.2.5.8.26.19SECTION 405.946
     405.946 Evidence to be submitted with the redetermination request.
42:2.0.1.2.5.8.26.20SECTION 405.947
     405.947 Notice to the beneficiary of applicable plan's request for a redetermination.
42:2.0.1.2.5.8.26.21SECTION 405.948
     405.948 Conduct of a redetermination.
42:2.0.1.2.5.8.26.22SECTION 405.950
     405.950 Time frame for making a redetermination.
42:2.0.1.2.5.8.26.23SECTION 405.952
     405.952 Withdrawal or dismissal of a request for a redetermination.
42:2.0.1.2.5.8.26.24SECTION 405.954
     405.954 Redetermination.
42:2.0.1.2.5.8.26.25SECTION 405.956
     405.956 Notice of a redetermination.
42:2.0.1.2.5.8.26.26SECTION 405.958
     405.958 Effect of a redetermination.
42:2.0.1.2.5.8.27SUBJGRP 27
  Reconsideration
42:2.0.1.2.5.8.27.27SECTION 405.960
     405.960 Right to a reconsideration.
42:2.0.1.2.5.8.27.28SECTION 405.962
     405.962 Timeframe for filing a request for a reconsideration.
42:2.0.1.2.5.8.27.29SECTION 405.964
     405.964 Place and method of filing a request for a reconsideration.
42:2.0.1.2.5.8.27.30SECTION 405.966
     405.966 Evidence to be submitted with the reconsideration request.
42:2.0.1.2.5.8.27.31SECTION 405.968
     405.968 Conduct of a reconsideration.
42:2.0.1.2.5.8.27.32SECTION 405.970
     405.970 Timeframe for making a reconsideration following a contractor redetermination.
42:2.0.1.2.5.8.27.33SECTION 405.972
     405.972 Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.
42:2.0.1.2.5.8.27.34SECTION 405.974
     405.974 Reconsideration and review of a contractor's dismissal of a request for redetermination.
42:2.0.1.2.5.8.27.35SECTION 405.976
     405.976 Notice of a reconsideration.
42:2.0.1.2.5.8.27.36SECTION 405.978
     405.978 Effect of a reconsideration.
42:2.0.1.2.5.8.28SUBJGRP 28
  Reopenings
42:2.0.1.2.5.8.28.37SECTION 405.980
     405.980 Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.
42:2.0.1.2.5.8.28.38SECTION 405.982
     405.982 Notice of a revised determination or decision.
42:2.0.1.2.5.8.28.39SECTION 405.984
     405.984 Effect of a revised determination or decision.
42:2.0.1.2.5.8.28.40SECTION 405.986
     405.986 Good cause for reopening.
42:2.0.1.2.5.8.29SUBJGRP 29
  Expedited Access to Judicial Review
42:2.0.1.2.5.8.29.41SECTION 405.990
     405.990 Expedited access to judicial review.
42:2.0.1.2.5.8.30SUBJGRP 30
  ALJ Hearings
42:2.0.1.2.5.8.30.42SECTION 405.1000
     405.1000 Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
42:2.0.1.2.5.8.30.43SECTION 405.1002
     405.1002 Right to an ALJ hearing.
42:2.0.1.2.5.8.30.44SECTION 405.1004
     405.1004 Right to a review of QIC notice of dismissal.
42:2.0.1.2.5.8.30.45SECTION 405.1006
     405.1006 Amount in controversy required for an ALJ hearing and judicial review.
42:2.0.1.2.5.8.30.46SECTION 405.1008
     405.1008 Parties to the proceedings on a request for an ALJ hearing.
42:2.0.1.2.5.8.30.47SECTION 405.1010
     405.1010 When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.
42:2.0.1.2.5.8.30.48SECTION 405.1012
     405.1012 When CMS or its contractors may be a party to a hearing.
42:2.0.1.2.5.8.30.49SECTION 405.1014
     405.1014 Request for an ALJ hearing or a review of a QIC dismissal.
42:2.0.1.2.5.8.30.50SECTION 405.1016
     405.1016 Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.
42:2.0.1.2.5.8.30.51SECTION 405.1018
     405.1018 Submitting evidence.
42:2.0.1.2.5.8.30.52SECTION 405.1020
     405.1020 Time and place for a hearing before an ALJ.
42:2.0.1.2.5.8.30.53SECTION 405.1022
     405.1022 Notice of a hearing before an ALJ.
42:2.0.1.2.5.8.30.54SECTION 405.1024
     405.1024 Objections to the issues.
42:2.0.1.2.5.8.30.55SECTION 405.1026
     405.1026 Disqualification of the ALJ or attorney adjudicator.
42:2.0.1.2.5.8.30.56SECTION 405.1028
     405.1028 Review of evidence submitted by parties.
42:2.0.1.2.5.8.30.57SECTION 405.1030
     405.1030 ALJ hearing procedures.
42:2.0.1.2.5.8.30.58SECTION 405.1032
     405.1032 Issues before an ALJ or attorney adjudicator.
42:2.0.1.2.5.8.30.59SECTION 405.1034
     405.1034 Requesting information from the QIC.
42:2.0.1.2.5.8.30.60SECTION 405.1036
     405.1036 Description of an ALJ hearing process.
42:2.0.1.2.5.8.30.61SECTION 405.1037
     405.1037 Discovery.
42:2.0.1.2.5.8.30.62SECTION 405.1038
     405.1038 Deciding a case without a hearing before an ALJ.
42:2.0.1.2.5.8.30.63SECTION 405.1040
     405.1040 Prehearing and posthearing conferences.
42:2.0.1.2.5.8.30.64SECTION 405.1042
     405.1042 The administrative record.
42:2.0.1.2.5.8.30.65SECTION 405.1044
     405.1044 Consolidated proceedings.
42:2.0.1.2.5.8.30.66SECTION 405.1046
     405.1046 Notice of an ALJ or attorney adjudicator decision.
42:2.0.1.2.5.8.30.67SECTION 405.1048
     405.1048 The effect of an ALJ's or attorney adjudicator's decision.
42:2.0.1.2.5.8.30.68SECTION 405.1050
     405.1050 Removal of a hearing request from OMHA to the Council.
42:2.0.1.2.5.8.30.69SECTION 405.1052
     405.1052 Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.
42:2.0.1.2.5.8.30.70SECTION 405.1054
     405.1054 Effect of dismissal of a request for a hearing or request for review of QIC dismissal.
42:2.0.1.2.5.8.30.71SECTION 405.1056
     405.1056 Remands of requests for hearing and requests for review.
42:2.0.1.2.5.8.30.72SECTION 405.1058
     405.1058 Effect of a remand.
42:2.0.1.2.5.8.31SUBJGRP 31
  Applicability of Medicare Coverage Policies
42:2.0.1.2.5.8.31.73SECTION 405.1060
     405.1060 Applicability of national coverage determinations (NCDs).
42:2.0.1.2.5.8.31.74SECTION 405.1062
     405.1062 Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.
42:2.0.1.2.5.8.31.75SECTION 405.1063
     405.1063 Applicability of laws, regulations, CMS Rulings, and precedential decisions.
42:2.0.1.2.5.8.32SUBJGRP 32
  Medicare Appeals Council Review
42:2.0.1.2.5.8.32.76SECTION 405.1100
     405.1100 Medicare Appeals Council review: General.
42:2.0.1.2.5.8.32.77SECTION 405.1102
     405.1102 Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
42:2.0.1.2.5.8.32.78SECTION 405.1106
     405.1106 Where a request for review or escalation may be filed.
42:2.0.1.2.5.8.32.79SECTION 405.1108
     405.1108 Council actions when request for review or escalation is filed.
42:2.0.1.2.5.8.32.80SECTION 405.1110
     405.1110 Council reviews on its own motion.
42:2.0.1.2.5.8.32.81SECTION 405.1112
     405.1112 Content of request for review.
42:2.0.1.2.5.8.32.82SECTION 405.1114
     405.1114 Dismissal of request for review.
42:2.0.1.2.5.8.32.83SECTION 405.1116
     405.1116 Effect of dismissal of request for Council review or request for hearing.
42:2.0.1.2.5.8.32.84SECTION 405.1118
     405.1118 Obtaining evidence from the Council.
42:2.0.1.2.5.8.32.85SECTION 405.1120
     405.1120 Filing briefs with the Council.
42:2.0.1.2.5.8.32.86SECTION 405.1122
     405.1122 What evidence may be submitted to the Council.
42:2.0.1.2.5.8.32.87SECTION 405.1124
     405.1124 Oral argument.
42:2.0.1.2.5.8.32.88SECTION 405.1126
     405.1126 Case remanded by the Council.
42:2.0.1.2.5.8.32.89SECTION 405.1128
     405.1128 Action of the Council.
42:2.0.1.2.5.8.32.90SECTION 405.1130
     405.1130 Effect of the Council's decision.
42:2.0.1.2.5.8.32.91SECTION 405.1132
     405.1132 Request for escalation to Federal court.
42:2.0.1.2.5.8.32.92SECTION 405.1134
     405.1134 Extension of time to file action in Federal district court.
42:2.0.1.2.5.8.32.93SECTION 405.1136
     405.1136 Judicial review.
42:2.0.1.2.5.8.32.94SECTION 405.1138
     405.1138 Case remanded by a Federal district court.
42:2.0.1.2.5.8.32.95SECTION 405.1140
     405.1140 Council review of ALJ decision in a case remanded by a Federal district court.
42:2.0.1.2.5.9SUBPART J
Subpart J - Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges
42:2.0.1.2.5.9.33.1SECTION 405.1200
     405.1200 Notifying beneficiaries of provider service terminations.
42:2.0.1.2.5.9.33.2SECTION 405.1202
     405.1202 Expedited determination procedures.
42:2.0.1.2.5.9.33.3SECTION 405.1204
     405.1204 Expedited reconsiderations.
42:2.0.1.2.5.9.33.4SECTION 405.1205
     405.1205 Notifying beneficiaries of hospital discharge appeal rights.
42:2.0.1.2.5.9.33.5SECTION 405.1206
     405.1206 Expedited determination procedures for inpatient hospital care.
42:2.0.1.2.5.9.33.6SECTION 405.1208
     405.1208 Hospital requests expedited QIO review.
42:2.0.1.2.5.10SUBPART K
Subparts K-Q [Reserved]
42:2.0.1.2.5.11SUBPART R
Subpart R - Provider Reimbursement Determinations and Appeals
42:2.0.1.2.5.11.33.1SECTION 405.1801
     405.1801 Introduction.
42:2.0.1.2.5.11.33.2SECTION 405.1803
     405.1803 Contractor determination and notice of amount of program reimbursement.
42:2.0.1.2.5.11.33.3SECTION 405.1804
     405.1804 Matters not subject to administrative and judicial review under prospective payment.
42:2.0.1.2.5.11.33.4SECTION 405.1805
     405.1805 Parties to contractor determination.
42:2.0.1.2.5.11.33.5SECTION 405.1807
     405.1807 Effect of contractor determination.
42:2.0.1.2.5.11.33.6SECTION 405.1809
     405.1809 Contractor hearing procedures.
42:2.0.1.2.5.11.33.7SECTION 405.1811
     405.1811 Right to contractor hearing; contents of, and adding issues to, hearing request.
42:2.0.1.2.5.11.33.8SECTION 405.1813
     405.1813 Good cause extension of time limit for requesting a contractor hearing.
42:2.0.1.2.5.11.33.9SECTION 405.1814
     405.1814 Contractor hearing officer jurisdiction.
42:2.0.1.2.5.11.33.10SECTION 405.1815
     405.1815 Parties to proceedings before the contractor hearing officer(s).
42:2.0.1.2.5.11.33.11SECTION 405.1817
     405.1817 Hearing officer or panel of hearing officers authorized to conduct contractor hearing; disqualification of officers.
42:2.0.1.2.5.11.33.12SECTION 405.1819
     405.1819 Conduct of contractor hearing.
42:2.0.1.2.5.11.33.13SECTION 405.1821
     405.1821 Prehearing discovery and other proceedings prior to the contractor hearing.
42:2.0.1.2.5.11.33.14SECTION 405.1823
     405.1823 Evidence at contractor hearing.
42:2.0.1.2.5.11.33.15SECTION 405.1825
     405.1825 Witnesses at contractor hearing.
42:2.0.1.2.5.11.33.16SECTION 405.1827
     405.1827 Record of proceedings before the contractor hearing officer(s).
42:2.0.1.2.5.11.33.17SECTION 405.1829
     405.1829 Scope of authority of contractor hearing officer(s).
42:2.0.1.2.5.11.33.18SECTION 405.1831
     405.1831 Contractor hearing decision.
42:2.0.1.2.5.11.33.19SECTION 405.1832
     405.1832 Contractor hearing officer review of compliance with the substantive reimbursement requirement of an appropriate cost report claim.
42:2.0.1.2.5.11.33.20SECTION 405.1833
     405.1833 Effect of contractor hearing decision.
42:2.0.1.2.5.11.33.21SECTION 405.1834
     405.1834 CMS reviewing official procedure.
42:2.0.1.2.5.11.33.22SECTION 405.1835
     405.1835 Right to Board hearing; contents of, and adding issues to, hearing request.
42:2.0.1.2.5.11.33.23SECTION 405.1836
     405.1836 Good cause extension of time limit for requesting a Board hearing.
42:2.0.1.2.5.11.33.24SECTION 405.1837
     405.1837 Group appeals.
42:2.0.1.2.5.11.33.25SECTION 405.1839
     405.1839 Amount in controversy.
42:2.0.1.2.5.11.33.26SECTION 405.1840
     405.1840 Board jurisdiction.
42:2.0.1.2.5.11.33.27SECTION 405.1842
     405.1842 Expedited judicial review.
42:2.0.1.2.5.11.33.28SECTION 405.1843
     405.1843 Parties to proceedings in a Board appeal.
42:2.0.1.2.5.11.33.29SECTION 405.1845
     405.1845 Composition of Board; hearings, decisions, and remands.
42:2.0.1.2.5.11.33.30SECTION 405.1847
     405.1847 Disqualification of Board members.
42:2.0.1.2.5.11.33.31SECTION 405.1849
     405.1849 Establishment of time and place of hearing by the Board.
42:2.0.1.2.5.11.33.32SECTION 405.1851
     405.1851 Conduct of Board hearing.
42:2.0.1.2.5.11.33.33SECTION 405.1853
     405.1853 Board proceedings prior to any hearing; discovery.
42:2.0.1.2.5.11.33.34SECTION 405.1855
     405.1855 Evidence at Board hearing.
42:2.0.1.2.5.11.33.35SECTION 405.1857
     405.1857 Subpoenas.
42:2.0.1.2.5.11.33.36SECTION 405.1859
     405.1859 Witnesses.
42:2.0.1.2.5.11.33.37SECTION 405.1861
     405.1861 Oral argument and written allegations.
42:2.0.1.2.5.11.33.38SECTION 405.1863
     405.1863 Administrative policy at issue.
42:2.0.1.2.5.11.33.39SECTION 405.1865
     405.1865 Record of administrative proceedings.
42:2.0.1.2.5.11.33.40SECTION 405.1867
     405.1867 Scope of Board's legal authority.
42:2.0.1.2.5.11.33.41SECTION 405.1868
     405.1868 Board actions in response to failure to follow Board rules.
42:2.0.1.2.5.11.33.42SECTION 405.1869
     405.1869 Scope of Board's authority in a hearing decision.
42:2.0.1.2.5.11.33.43SECTION 405.1871
     405.1871 Board hearing decision.
42:2.0.1.2.5.11.33.44SECTION 405.1873
     405.1873 Board review of compliance with the reimbursement requirement of an appropriate cost report claim.
42:2.0.1.2.5.11.33.45SECTION 405.1875
     405.1875 Administrator review.
42:2.0.1.2.5.11.33.46SECTION 405.1877
     405.1877 Judicial review.
42:2.0.1.2.5.11.33.47SECTION 405.1881
     405.1881 Appointment of representative.
42:2.0.1.2.5.11.33.48SECTION 405.1883
     405.1883 Authority of representative.
42:2.0.1.2.5.11.33.49SECTION 405.1885
     405.1885 Reopening a contractor determination or reviewing entity decision.
42:2.0.1.2.5.11.33.50SECTION 405.1887
     405.1887 Notice of reopening; effect of reopening.
42:2.0.1.2.5.11.33.51SECTION 405.1889
     405.1889 Effect of a revision; issue-specific nature of appeals of revised determinations and decisions.
42:2.0.1.2.5.12SUBPART S
Subparts S-T [Reserved]
42:2.0.1.2.5.13SUBPART U
Subpart U - Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services
42:2.0.1.2.5.13.33.1SECTION 405.2100-405.2101
     405.2100-405.2101 [Reserved]
42:2.0.1.2.5.13.33.2SECTION 405.2102
     405.2102 Definitions.
42:2.0.1.2.5.13.33.3SECTION 405.2110
     405.2110 Designation of ESRD networks.
42:2.0.1.2.5.13.33.4SECTION 405.2111
     405.2111 [Reserved]
42:2.0.1.2.5.13.33.5SECTION 405.2112
     405.2112 ESRD network organizations.
42:2.0.1.2.5.13.33.6SECTION 405.2113
     405.2113 Medical review board.
42:2.0.1.2.5.13.33.7SECTION 405.2114
     405.2114 [Reserved]
42:2.0.1.2.5.13.33.8SECTION 405.2131-405.2184
     405.2131-405.2184 [Reserved]
42:2.0.1.2.5.14SUBPART V
Subparts V-W [Reserved]
42:2.0.1.2.5.15SUBPART X
Subpart X - Rural Health Clinic and Federally Qualified Health Center Services
42:2.0.1.2.5.15.33SUBJGRP 33
  Federally Qualified Health Center Services
42:2.0.1.2.5.15.33.1SECTION 405.2400
     405.2400 Basis.
42:2.0.1.2.5.15.33.2SECTION 405.2401
     405.2401 Scope and definitions.
42:2.0.1.2.5.15.33.3SECTION 405.2402
     405.2402 Rural health clinic basic requirements.
42:2.0.1.2.5.15.33.4SECTION 405.2403
     405.2403 Rural health clinic content and terms of the agreement with the Secretary.
42:2.0.1.2.5.15.33.5SECTION 405.2404
     405.2404 Termination of rural health clinic agreements.
42:2.0.1.2.5.15.33.6SECTION 405.2410
     405.2410 Application of Part B deductible and coinsurance.
42:2.0.1.2.5.15.33.7SECTION 405.2411
     405.2411 Scope of benefits.
42:2.0.1.2.5.15.33.8SECTION 405.2412
     405.2412 Physicians' services.
42:2.0.1.2.5.15.33.9SECTION 405.2413
     405.2413 Services and supplies incident to a physician's services.
42:2.0.1.2.5.15.33.10SECTION 405.2414
     405.2414 Nurse practitioner, physician assistant, and certified nurse midwife services.
42:2.0.1.2.5.15.33.11SECTION 405.2415
     405.2415 Incident to services and direct supervision.
42:2.0.1.2.5.15.33.12SECTION 405.2416
     405.2416 Visiting nurse services.
42:2.0.1.2.5.15.33.13SECTION 405.2417
     405.2417 Visiting nurse services: Determination of shortage of agencies.
42:2.0.1.2.5.15.33.14SECTION 405.2430
     405.2430 Basic requirements.
42:2.0.1.2.5.15.33.15SECTION 405.2434
     405.2434 Content and terms of the agreement.
42:2.0.1.2.5.15.33.16SECTION 405.2436
     405.2436 Termination of agreement.
42:2.0.1.2.5.15.33.17SECTION 405.2440
     405.2440 Conditions for reinstatement after termination by CMS.
42:2.0.1.2.5.15.33.18SECTION 405.2442
     405.2442 Notice to the public.
42:2.0.1.2.5.15.33.19SECTION 405.2444
     405.2444 Change of ownership.
42:2.0.1.2.5.15.33.20SECTION 405.2446
     405.2446 Scope of services.
42:2.0.1.2.5.15.33.21SECTION 405.2448
     405.2448 Preventive primary services.
42:2.0.1.2.5.15.33.22SECTION 405.2449
     405.2449 Preventive services.
42:2.0.1.2.5.15.33.23SECTION 405.2450
     405.2450 Clinical psychologist and clinical social worker services.
42:2.0.1.2.5.15.33.24SECTION 405.2452
     405.2452 Services and supplies incident to clinical psychologist and clinical social worker services.
42:2.0.1.2.5.15.34SUBJGRP 34
  Payment for Rural Health Clinic and Federally Qualified Health Center Services
42:2.0.1.2.5.15.34.25SECTION 405.2460
     405.2460 Applicability of general payment exclusions.
42:2.0.1.2.5.15.34.26SECTION 405.2462
     405.2462 Payment for RHC and FQHC services.
42:2.0.1.2.5.15.34.27SECTION 405.2463
     405.2463 What constitutes a visit.
42:2.0.1.2.5.15.34.28SECTION 405.2464
     405.2464 Payment rate.
42:2.0.1.2.5.15.34.29SECTION 405.2466
     405.2466 Annual reconciliation.
42:2.0.1.2.5.15.34.30SECTION 405.2467
     405.2467 Requirements of the FQHC PPS.
42:2.0.1.2.5.15.34.31SECTION 405.2468
     405.2468 Allowable costs.
42:2.0.1.2.5.15.34.32SECTION 405.2469
     405.2469 FQHC supplemental payments.
42:2.0.1.2.5.15.34.33SECTION 405.2470
     405.2470 Reports and maintenance of records.
42:2.0.1.2.5.15.34.34SECTION 405.2472
     405.2472 Beneficiary appeals.
42:2.0.1.2.6PART 406
PART 406 - HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT
42:2.0.1.2.6.1SUBPART A
Subpart A - General Provisions
42:2.0.1.2.6.1.35.1SECTION 406.1
     406.1 Statutory basis.
42:2.0.1.2.6.1.35.2SECTION 406.2
     406.2 Scope.
42:2.0.1.2.6.1.35.3SECTION 406.3
     406.3 Definitions.
42:2.0.1.2.6.1.35.4SECTION 406.5
     406.5 Basis of eligibility and entitlement.
42:2.0.1.2.6.1.35.5SECTION 406.6
     406.6 Application or enrollment for hospital insurance.
42:2.0.1.2.6.1.35.6SECTION 406.7
     406.7 Forms to apply for entitlement under Medicare Part A.
42:2.0.1.2.6.2SUBPART B
Subpart B - Hospital Insurance Without Monthly Premiums
42:2.0.1.2.6.2.35.1SECTION 406.10
     406.10 Individual age 65 or over who is entitled to social security or railroad retirement benefits, or who is eligible for social security benefits.
42:2.0.1.2.6.2.35.2SECTION 406.11
     406.11 Individual age 65 or over who is not eligible as a social security or railroad retirement benefits beneficiary, or on the basis of government employment.
42:2.0.1.2.6.2.35.3SECTION 406.12
     406.12 Individual under age 65 who is entitled to social security or railroad retirement disability benefits.
42:2.0.1.2.6.2.35.4SECTION 406.13
     406.13 Individual who has end-stage renal disease.
42:2.0.1.2.6.2.35.5SECTION 406.15
     406.15 Special provisions applicable to Medicare qualified government employment.
42:2.0.1.2.6.3SUBPART C
Subpart C - Premium Hospital Insurance
42:2.0.1.2.6.3.35.1SECTION 406.20
     406.20 Basic requirements.
42:2.0.1.2.6.3.35.2SECTION 406.21
     406.21 Individual enrollment.
42:2.0.1.2.6.3.35.3SECTION 406.22
     406.22 Effect of month of enrollment on entitlement.
42:2.0.1.2.6.3.35.4SECTION 406.24
     406.24 Special enrollment period related to coverage under group health plans.
42:2.0.1.2.6.3.35.5SECTION 406.25
     406.25 Special enrollment period for volunteers outside the United States.
42:2.0.1.2.6.3.35.6SECTION 406.26
     406.26 Enrollment under State buy-in.
42:2.0.1.2.6.3.35.7SECTION 406.28
     406.28 End of entitlement.
42:2.0.1.2.6.3.35.8SECTION 406.32
     406.32 Monthly premiums.
42:2.0.1.2.6.3.35.9SECTION 406.33
     406.33 Determination of months to be counted for premium increase: Enrollment.
42:2.0.1.2.6.3.35.10SECTION 406.34
     406.34 Determination of months to be counted for premium increase: Reenrollment.
42:2.0.1.2.6.3.35.11SECTION 406.38
     406.38 Prejudice to enrollment rights because of Federal Government error.
42:2.0.1.2.6.4SUBPART D
Subpart D - Special Circumstances That Affect Entitlement to Hospital Insurance
42:2.0.1.2.6.4.35.1SECTION 406.50
     406.50 Nonpayment of benefits on behalf of certain aliens.
42:2.0.1.2.6.4.35.2SECTION 406.52
     406.52 Conviction of certain offenses.
42:2.0.1.2.7PART 407
PART 407 - SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT
42:2.0.1.2.7.1SUBPART A
Subpart A - General Provisions
42:2.0.1.2.7.1.35.1SECTION 407.1
     407.1 Basis and scope.
42:2.0.1.2.7.1.35.2SECTION 407.2
     407.2 General description of program.
42:2.0.1.2.7.1.35.3SECTION 407.4
     407.4 Basic requirements for entitlement.
42:2.0.1.2.7.2SUBPART B
Subpart B - Individual Enrollment and Entitlement for SMI
42:2.0.1.2.7.2.35.1SECTION 407.10
     407.10 Eligibility to enroll.
42:2.0.1.2.7.2.35.2SECTION 407.11
     407.11 Forms used to apply for enrollment under Medicare Part B.
42:2.0.1.2.7.2.35.3SECTION 407.12
     407.12 General enrollment provisions.
42:2.0.1.2.7.2.35.4SECTION 407.14
     407.14 Initial enrollment period.
42:2.0.1.2.7.2.35.5SECTION 407.15
     407.15 General enrollment period.
42:2.0.1.2.7.2.35.6SECTION 407.17
     407.17 Automatic enrollment.
42:2.0.1.2.7.2.35.7SECTION 407.18
     407.18 Determining month of automatic enrollment.
42:2.0.1.2.7.2.35.8SECTION 407.20
     407.20 Special enrollment period related to coverage under group health plans.
42:2.0.1.2.7.2.35.9SECTION 407.21
     407.21 Special enrollment period for volunteers outside the United States.
42:2.0.1.2.7.2.35.10SECTION 407.22
     407.22 Request for individual enrollment.
42:2.0.1.2.7.2.35.11SECTION 407.25
     407.25 Beginning of entitlement: Individual enrollment.
42:2.0.1.2.7.2.35.12SECTION 407.27
     407.27 Termination of entitlement: Individual enrollment.
42:2.0.1.2.7.2.35.13SECTION 407.30
     407.30 Limitations on enrollment.
42:2.0.1.2.7.2.35.14SECTION 407.32
     407.32 Prejudice to enrollment rights because of Federal Government misrepresentation, inaction, or error.
42:2.0.1.2.7.3SUBPART C
Subpart C - State Buy-In Agreements
42:2.0.1.2.7.3.35.1SECTION 407.40
     407.40 Enrollment under a State buy-in agreement.
42:2.0.1.2.7.3.35.2SECTION 407.42
     407.42 Buy-in groups available to the 50 States, the District of Columbia, and the Northern Mariana Islands.
42:2.0.1.2.7.3.35.3SECTION 407.43
     407.43 Buy-in groups available to Puerto Rico, Guam, the Virgin Islands, and American Samoa.
42:2.0.1.2.7.3.35.4SECTION 407.45
     407.45 Termination of State buy-in agreements.
42:2.0.1.2.7.3.35.5SECTION 407.47
     407.47 Beginning of coverage under a State buy-in agreement.
42:2.0.1.2.7.3.35.6SECTION 407.48
     407.48 Termination of coverage under a State buy-in agreement.
42:2.0.1.2.7.3.35.7SECTION 407.50
     407.50 Continuation of coverage: Individual enrollment following end of coverage under a State buy-in agreement.
42:2.0.1.2.8PART 408
PART 408 - PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE
42:2.0.1.2.8.1SUBPART A
Subpart A - General Provisions
42:2.0.1.2.8.1.35.1SECTION 408.1
     408.1 Statutory basis.
42:2.0.1.2.8.1.35.2SECTION 408.2
     408.2 Scope and purpose.
42:2.0.1.2.8.1.35.3SECTION 408.3
     408.3 Definitions.
42:2.0.1.2.8.1.35.4SECTION 408.4
     408.4 Payment obligations.
42:2.0.1.2.8.1.35.5SECTION 408.6
     408.6 Methods and priorities for payment.
42:2.0.1.2.8.1.35.6SECTION 408.8
     408.8 Grace period and termination date.
42:2.0.1.2.8.1.35.7SECTION 408.10
     408.10 Claim for monthly benefits pending concurrently with request for SMI enrollment.
42:2.0.1.2.8.2SUBPART B
Subpart B - Amount of Monthly Premiums
42:2.0.1.2.8.2.35.1SECTION 408.20
     408.20 Monthly premiums.
42:2.0.1.2.8.2.35.2SECTION 408.21
     408.21 Reduction in Medicare Part B premium as an additional benefit under Medicare + Choice plans.
42:2.0.1.2.8.2.35.3SECTION 408.22
     408.22 Increased premiums for late enrollment and for reenrollment.
42:2.0.1.2.8.2.35.4SECTION 408.24
     408.24 Individuals who enrolled or reenrolled before April 1, 1981 or after September 30, 1981.
42:2.0.1.2.8.2.35.5SECTION 408.25
     408.25 Individuals who enrolled or reenrolled between April 1 and September 30, 1981.
42:2.0.1.2.8.2.35.6SECTION 408.26
     408.26 Examples.
42:2.0.1.2.8.2.35.7SECTION 408.27
     408.27 Rounding the monthly premium.
42:2.0.1.2.8.2.35.8SECTION 408.28
     408.28 Increased premiums due to the income-related monthly adjustment amount (IRMAA).
42:2.0.1.2.8.3SUBPART C
Subpart C - Deduction From Monthly Benefits
42:2.0.1.2.8.3.35.1SECTION 408.40
     408.40 Deduction from monthly benefits: Basic rules.
42:2.0.1.2.8.3.35.2SECTION 408.42
     408.42 Deduction from railroad retirement benefits.
42:2.0.1.2.8.3.35.3SECTION 408.43
     408.43 Deduction from social security benefits.
42:2.0.1.2.8.3.35.4SECTION 408.44
     408.44 Deduction from civil service annuities.
42:2.0.1.2.8.3.35.5SECTION 408.45
     408.45 Deduction from age 72 special payments.
42:2.0.1.2.8.3.35.6SECTION 408.46
     408.46 Effect of suspension of social security benefits.
42:2.0.1.2.8.3.35.7SECTION 408.47
     408.47 [Reserved]
42:2.0.1.2.8.3.35.8SECTION 408.50
     408.50 When premiums are considered paid.
42:2.0.1.2.8.3.35.9SECTION 408.52
     408.52 Change from direct remittance to deduction.
42:2.0.1.2.8.3.35.10SECTION 408.53
     408.53 Change from partial direct remittance to full deduction.
42:2.0.1.2.8.4SUBPART D
Subpart D - Direct Remittance: Individual Payment
42:2.0.1.2.8.4.35.1SECTION 408.60
     408.60 Direct remittance: Basic rules.
42:2.0.1.2.8.4.35.2SECTION 408.62
     408.62 Initial and subsequent billings.
42:2.0.1.2.8.4.35.3SECTION 408.63
     408.63 Billing procedures when monthly benefits are less than monthly premiums.
42:2.0.1.2.8.4.35.4SECTION 408.65
     408.65 Payment options.
42:2.0.1.2.8.4.35.5SECTION 408.68
     408.68 When premiums are considered paid.
42:2.0.1.2.8.4.35.6SECTION 408.70
     408.70 Change from quarterly to monthly payments.
42:2.0.1.2.8.4.35.7SECTION 408.71
     408.71 Change from deduction or State payment to direct remittance.
42:2.0.1.2.8.5SUBPART E
Subpart E - Direct Remittance: Group Payment
42:2.0.1.2.8.5.35.1SECTION 408.80
     408.80 Basic rules.
42:2.0.1.2.8.5.35.2SECTION 408.82
     408.82 Conditions for group billing.
42:2.0.1.2.8.5.35.3SECTION 408.84
     408.84 Billing and payment procedures.
42:2.0.1.2.8.5.35.4SECTION 408.86
     408.86 Responsibilities under group billing arrangement.
42:2.0.1.2.8.5.35.5SECTION 408.88
     408.88 Refund of group payments.
42:2.0.1.2.8.5.35.6SECTION 408.90
     408.90 Termination of group billing arrangement.
42:2.0.1.2.8.5.35.7SECTION 408.92
     408.92 Change from group payment to deduction or individual payment.
42:2.0.1.2.8.6SUBPART F
Subpart F - Termination and Reinstatement of Coverage
42:2.0.1.2.8.6.35.1SECTION 408.100
     408.100 Termination of coverage for nonpayment of premiums.
42:2.0.1.2.8.6.35.2SECTION 408.102
     408.102 Reconsideration of termination.
42:2.0.1.2.8.6.35.3SECTION 408.104
     408.104 Reinstatement procedures.
42:2.0.1.2.8.7SUBPART G
Subpart G - Collection of Unpaid Premiums; Refund of Excess Premiums After the Death of the Enrollee
42:2.0.1.2.8.7.35.1SECTION 408.110
     408.110 Collection of unpaid premiums.
42:2.0.1.2.8.7.35.2SECTION 408.112
     408.112 Refund of excess premiums after the enrollee dies.
42:2.0.1.2.8.8SUBPART H
Subpart H - Supplementary Medical Insurance Premium Surcharge Agreements
42:2.0.1.2.8.8.35.1SECTION 408.200
     408.200 Statutory basis.
42:2.0.1.2.8.8.35.2SECTION 408.201
     408.201 Definitions.
42:2.0.1.2.8.8.35.3SECTION 408.202
     408.202 Conditions for participation.
42:2.0.1.2.8.8.35.4SECTION 408.205
     408.205 Application procedures.
42:2.0.1.2.8.8.35.5SECTION 408.207
     408.207 Billing and payment procedures.
42:2.0.1.2.8.8.35.6SECTION 408.210
     408.210 Termination of SMI premium surcharge agreement.
42:2.0.1.2.9PART 409
PART 409 - HOSPITAL INSURANCE BENEFITS
42:2.0.1.2.9.1SUBPART A
Subpart A - Hospital Insurance Benefits: General Provisions
42:2.0.1.2.9.1.35.1SECTION 409.1
     409.1 Statutory basis.
42:2.0.1.2.9.1.35.2SECTION 409.2
     409.2 Scope.
42:2.0.1.2.9.1.35.3SECTION 409.3
     409.3 Definitions.
42:2.0.1.2.9.1.35.4SECTION 409.5
     409.5 General description of benefits.
42:2.0.1.2.9.2SUBPART B
Subpart B - Inpatient Hospital Services and Inpatient Critical Access Hospital Services
42:2.0.1.2.9.2.35.1SECTION 409.10
     409.10 Included services.
42:2.0.1.2.9.2.35.2SECTION 409.11
     409.11 Bed and board.
42:2.0.1.2.9.2.35.3SECTION 409.12
     409.12 Nursing and related services, medical social services; use of hospital or CAH facilities.
42:2.0.1.2.9.2.35.4SECTION 409.13
     409.13 Drugs and biologicals.
42:2.0.1.2.9.2.35.5SECTION 409.14
     409.14 Supplies, appliances, and equipment.
42:2.0.1.2.9.2.35.6SECTION 409.15
     409.15 Services furnished by an intern or a resident-in-training.
42:2.0.1.2.9.2.35.7SECTION 409.16
     409.16 Other diagnostic or therapeutic services.
42:2.0.1.2.9.2.35.8SECTION 409.17
     409.17 Physical therapy, occupational therapy, and speech-language pathology services.
42:2.0.1.2.9.2.35.9SECTION 409.18
     409.18 Services related to kidney transplantations.
42:2.0.1.2.9.3SUBPART C
Subpart C - Posthospital SNF Care
42:2.0.1.2.9.3.35.1SECTION 409.20
     409.20 Coverage of services.
42:2.0.1.2.9.3.35.2SECTION 409.21
     409.21 Nursing care.
42:2.0.1.2.9.3.35.3SECTION 409.22
     409.22 Bed and board.
42:2.0.1.2.9.3.35.4SECTION 409.23
     409.23 Physical therapy, occupational therapy, and speech-language pathology services.
42:2.0.1.2.9.3.35.5SECTION 409.24
     409.24 Medical social services.
42:2.0.1.2.9.3.35.6SECTION 409.25
     409.25 Drugs, biologicals, supplies, appliances, and equipment.
42:2.0.1.2.9.3.35.7SECTION 409.26
     409.26 Transfer agreement hospital services.
42:2.0.1.2.9.3.35.8SECTION 409.27
     409.27 Other services generally provided by (or under arrangements made by) SNFs.
42:2.0.1.2.9.4SUBPART D
Subpart D - Requirements for Coverage of Posthospital SNF Care
42:2.0.1.2.9.4.35.1SECTION 409.30
     409.30 Basic requirements.
42:2.0.1.2.9.4.35.2SECTION 409.31
     409.31 Level of care requirement.
42:2.0.1.2.9.4.35.3SECTION 409.32
     409.32 Criteria for skilled services and the need for skilled services.
42:2.0.1.2.9.4.35.4SECTION 409.33
     409.33 Examples of skilled nursing and rehabilitation services.
42:2.0.1.2.9.4.35.5SECTION 409.34
     409.34 Criteria for “daily basis”.
42:2.0.1.2.9.4.35.6SECTION 409.35
     409.35 Criteria for “practical matter”.
42:2.0.1.2.9.4.35.7SECTION 409.36
     409.36 Effect of discharge from posthospital SNF care.
42:2.0.1.2.9.5SUBPART E
Subpart E - Home Health Services Under Hospital Insurance
42:2.0.1.2.9.5.35.1SECTION 409.40
     409.40 Basis, purpose, and scope.
42:2.0.1.2.9.5.35.2SECTION 409.41
     409.41 Requirement for payment.
42:2.0.1.2.9.5.35.3SECTION 409.42
     409.42 Beneficiary qualifications for coverage of services.
42:2.0.1.2.9.5.35.4SECTION 409.43
     409.43 Plan of care requirements.
42:2.0.1.2.9.5.35.5SECTION 409.44
     409.44 Skilled services requirements.
42:2.0.1.2.9.5.35.6SECTION 409.45
     409.45 Dependent services requirements.
42:2.0.1.2.9.5.35.7SECTION 409.46
     409.46 Allowable administrative costs.
42:2.0.1.2.9.5.35.8SECTION 409.47
     409.47 Place of service requirements.
42:2.0.1.2.9.5.35.9SECTION 409.48
     409.48 Visits.
42:2.0.1.2.9.5.35.10SECTION 409.49
     409.49 Excluded services.
42:2.0.1.2.9.5.35.11SECTION 409.50
     409.50 Coinsurance for durable medical equipment (DME) and applicable disposable devices furnished as a home health service.
42:2.0.1.2.9.6SUBPART F
Subpart F - Scope of Hospital Insurance Benefits
42:2.0.1.2.9.6.35.1SECTION 409.60
     409.60 Benefit periods.
42:2.0.1.2.9.6.35.2SECTION 409.61
     409.61 General limitations on amount of benefits.
42:2.0.1.2.9.6.35.3SECTION 409.62
     409.62 Lifetime maximum on inpatient psychiatric care.
42:2.0.1.2.9.6.35.4SECTION 409.63
     409.63 Reduction of inpatient psychiatric benefit days available in the initial benefit period.
42:2.0.1.2.9.6.35.5SECTION 409.64
     409.64 Services that are counted toward allowable amounts.
42:2.0.1.2.9.6.35.6SECTION 409.65
     409.65 Lifetime reserve days.
42:2.0.1.2.9.6.35.7SECTION 409.66
     409.66 Revocation of election not to use lifetime reserve days.
42:2.0.1.2.9.6.35.8SECTION 409.68
     409.68 Guarantee of payment for inpatient hospital or inpatient CAH services furnished before notification of exhaustion of benefits.
42:2.0.1.2.9.7SUBPART G
Subpart G - Hospital Insurance Deductibles and Coinsurance
42:2.0.1.2.9.7.35.1SECTION 409.80
     409.80 Inpatient deductible and coinsurance: General provisions.
42:2.0.1.2.9.7.35.2SECTION 409.82
     409.82 Inpatient hospital deductible.
42:2.0.1.2.9.7.35.3SECTION 409.83
     409.83 Inpatient hospital coinsurance.
42:2.0.1.2.9.7.35.4SECTION 409.85
     409.85 Skilled nursing facility (SNF) care coinsurance.
42:2.0.1.2.9.7.35.5SECTION 409.87
     409.87 Blood deductible.
42:2.0.1.2.9.7.35.6SECTION 409.89
     409.89 Exemption of kidney donors from deductible and coinsurance requirements.
42:2.0.1.2.9.8SUBPART H
Subpart H - Payment of Hospital Insurance Benefits
42:2.0.1.2.9.8.35.1SECTION 409.100
     409.100 To whom payment is made.
42:2.0.1.2.9.8.35.2SECTION 409.102
     409.102 Amounts of payment.
42:2.0.1.2.10PART 410
PART 410 - SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
42:2.0.1.2.10.1SUBPART A
Subpart A - General Provisions
42:2.0.1.2.10.1.35.1SECTION 410.1
     410.1 Basis and scope.
42:2.0.1.2.10.1.35.2SECTION 410.2
     410.2 Definitions.
42:2.0.1.2.10.1.35.3SECTION 410.3
     410.3 Scope of benefits.
42:2.0.1.2.10.1.35.4SECTION 410.5
     410.5 Other applicable rules.
42:2.0.1.2.10.2SUBPART B
Subpart B - Medical and Other Health Services
42:2.0.1.2.10.2.35.1SECTION 410.10
     410.10 Medical and other health services: Included services.
42:2.0.1.2.10.2.35.2SECTION 410.12
     410.12 Medical and other health services: Basic conditions and limitations.
42:2.0.1.2.10.2.35.3SECTION 410.14
     410.14 Special requirements for services furnished outside the United States.
42:2.0.1.2.10.2.35.4SECTION 410.15
     410.15 Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage.
42:2.0.1.2.10.2.35.5SECTION 410.16
     410.16 Initial preventive physical examination: Conditions for and limitations on coverage.
42:2.0.1.2.10.2.35.6SECTION 410.17
     410.17 Cardiovascular disease screening tests.
42:2.0.1.2.10.2.35.7SECTION 410.18
     410.18 Diabetes screening tests.
42:2.0.1.2.10.2.35.8SECTION 410.19
     410.19 Ultrasound screening for abdominal aortic aneurysms: Condition for and limitation on coverage.
42:2.0.1.2.10.2.35.9SECTION 410.20
     410.20 Physicians' services.
42:2.0.1.2.10.2.35.10SECTION 410.21
     410.21 Limitations on services of a chiropractor.
42:2.0.1.2.10.2.35.11SECTION 410.22
     410.22 Limitations on services of an optometrist.
42:2.0.1.2.10.2.35.12SECTION 410.23
     410.23 Screening for glaucoma: Conditions for and limitations on coverage.
42:2.0.1.2.10.2.35.13SECTION 410.24
     410.24 Limitations on services of a doctor of dental surgery or dental medicine.
42:2.0.1.2.10.2.35.14SECTION 410.25
     410.25 Limitations on services of a podiatrist.
42:2.0.1.2.10.2.35.15SECTION 410.26
     410.26 Services and supplies incident to a physician's professional services: Conditions.
42:2.0.1.2.10.2.35.16SECTION 410.27
     410.27 Therapeutic outpatient hospital or CAH services and supplies incident to a physician's or nonphysician practitioner's service: Conditions.
42:2.0.1.2.10.2.35.17SECTION 410.28
     410.28 Hospital or CAH diagnostic services furnished to outpatients: Conditions.
42:2.0.1.2.10.2.35.18SECTION 410.29
     410.29 Limitations on drugs and biologicals.
42:2.0.1.2.10.2.35.19SECTION 410.30
     410.30 Prescription drugs used in immunosuppressive therapy.
42:2.0.1.2.10.2.35.20SECTION 410.31
     410.31 Bone mass measurement: Conditions for coverage and frequency standards.
42:2.0.1.2.10.2.35.21SECTION 410.32
     410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
42:2.0.1.2.10.2.35.22SECTION 410.33
     410.33 Independent diagnostic testing facility.
42:2.0.1.2.10.2.35.23SECTION 410.34
     410.34 Mammography services: Conditions for and limitations on coverage.
42:2.0.1.2.10.2.35.24SECTION 410.35
     410.35 X-ray therapy and other radiation therapy services: Scope.
42:2.0.1.2.10.2.35.25SECTION 410.36
     410.36 Medical supplies, appliances, and devices: Scope.
42:2.0.1.2.10.2.35.26SECTION 410.37
     410.37 Colorectal cancer screening tests: Conditions for and limitations on coverage.
42:2.0.1.2.10.2.35.27SECTION 410.38
     410.38 Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions.
42:2.0.1.2.10.2.35.28SECTION 410.39
     410.39 Prostate cancer screening tests: Conditions for and limitations on coverage.
42:2.0.1.2.10.2.35.29SECTION 410.40
     410.40 Coverage of ambulance services.
42:2.0.1.2.10.2.35.30SECTION 410.41
     410.41 Requirements for ambulance providers and suppliers.
42:2.0.1.2.10.2.35.31SECTION 410.42
     410.42 Limitations on coverage of certain services furnished to hospital outpatients.
42:2.0.1.2.10.2.35.32SECTION 410.43
     410.43 Partial hospitalization services: Conditions and exclusions.
42:2.0.1.2.10.2.35.33SECTION 410.45
     410.45 Rural health clinic services: Scope and conditions.
42:2.0.1.2.10.2.35.34SECTION 410.46
     410.46 Physician and other practitioner services furnished in or at the direction of an IHS or Indian tribal hospital or clinic: Scope and conditions.
42:2.0.1.2.10.2.35.35SECTION 410.47
     410.47 Pulmonary rehabilitation program: Conditions for coverage.
42:2.0.1.2.10.2.35.36SECTION 410.48
     410.48 Kidney disease education services.
42:2.0.1.2.10.2.35.37SECTION 410.49
     410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage.
42:2.0.1.2.10.2.35.38SECTION 410.50
     410.50 Institutional dialysis services and supplies: Scope and conditions.
42:2.0.1.2.10.2.35.39SECTION 410.52
     410.52 Home dialysis services, supplies, and equipment: Scope and conditions.
42:2.0.1.2.10.2.35.40SECTION 410.55
     410.55 Services related to kidney donations: Conditions.
42:2.0.1.2.10.2.35.41SECTION 410.56
     410.56 Screening pelvic examinations.
42:2.0.1.2.10.2.35.42SECTION 410.57
     410.57 Pneumococcal vaccine and flu vaccine.
42:2.0.1.2.10.2.35.43SECTION 410.58
     410.58 Additional services to HMO and CMP enrollees.
42:2.0.1.2.10.2.35.44SECTION 410.59
     410.59 Outpatient occupational therapy services: Conditions.
42:2.0.1.2.10.2.35.45SECTION 410.60
     410.60 Outpatient physical therapy services: Conditions.
42:2.0.1.2.10.2.35.46SECTION 410.61
     410.61 Plan of treatment requirements for outpatient rehabilitation services.
42:2.0.1.2.10.2.35.47SECTION 410.62
     410.62 Outpatient speech-language pathology services: Conditions and exclusions.
42:2.0.1.2.10.2.35.48SECTION 410.63
     410.63 Hepatitis B vaccine and blood clotting factors: Conditions.
42:2.0.1.2.10.2.35.49SECTION 410.64
     410.64 Additional preventive services.
42:2.0.1.2.10.2.35.50SECTION 410.66
     410.66 Emergency outpatient services furnished by a nonparticipating hospital and services furnished in a foreign country.
42:2.0.1.2.10.2.35.51SECTION 410.67
     410.67 Medicare coverage and payment of Opioid use disorder treatment services furnished by Opioid treatment programs.
42:2.0.1.2.10.2.35.52SECTION 410.68
     410.68 Antigens: Scope and conditions.
42:2.0.1.2.10.2.35.53SECTION 410.69
     410.69 Services of a certified registered nurse anesthetist or an anesthesiologist's assistant: Basic rule and definitions.
42:2.0.1.2.10.2.35.54SECTION 410.71
     410.71 Clinical psychologist services and services and supplies incident to clinical psychologist services.
42:2.0.1.2.10.2.35.55SECTION 410.73
     410.73 Clinical social worker services.
42:2.0.1.2.10.2.35.56SECTION 410.74
     410.74 Physician assistants' services.
42:2.0.1.2.10.2.35.57SECTION 410.75
     410.75 Nurse practitioners' services.
42:2.0.1.2.10.2.35.58SECTION 410.76
     410.76 Clinical nurse specialists' services.
42:2.0.1.2.10.2.35.59SECTION 410.77
     410.77 Certified nurse-midwives' services: Qualifications and conditions.
42:2.0.1.2.10.2.35.60SECTION 410.78
     410.78 Telehealth services.
42:2.0.1.2.10.2.35.61SECTION 410.79
     410.79 Medicare Diabetes Prevention Program expanded model: Conditions of coverage.
42:2.0.1.2.10.3SUBPART C
Subpart C - Home Health Services Under SMI
42:2.0.1.2.10.3.35.1SECTION 410.80
     410.80 Applicable rules.
42:2.0.1.2.10.4SUBPART D
Subpart D - Comprehensive Outpatient Rehabilitation Facility (CORF) Services
42:2.0.1.2.10.4.35.1SECTION 410.100
     410.100 Included services.
42:2.0.1.2.10.4.35.2SECTION 410.102
     410.102 Excluded services.
42:2.0.1.2.10.4.35.3SECTION 410.105
     410.105 Requirements for coverage of CORF services.
42:2.0.1.2.10.5SUBPART E
Subpart E - Community Mental Health Centers (CMHCs) Providing Partial Hospitalization Services
42:2.0.1.2.10.5.35.1SECTION 410.110
     410.110 Requirements for coverage of partial hospitalization services by CMHCs.
42:2.0.1.2.10.6SUBPART F
Subpart F [Reserved]
42:2.0.1.2.10.7SUBPART G
Subpart G - Medical Nutrition Therapy
42:2.0.1.2.10.7.35.1SECTION 410.130
     410.130 Definitions.
42:2.0.1.2.10.7.35.2SECTION 410.132
     410.132 Medical nutrition therapy.
42:2.0.1.2.10.7.35.3SECTION 410.134
     410.134 Provider qualifications.
42:2.0.1.2.10.8SUBPART H
Subpart H - Outpatient Diabetes Self-Management Training and Diabetes Outcome Measurements
42:2.0.1.2.10.8.35.1SECTION 410.140
     410.140 Definitions.
42:2.0.1.2.10.8.35.2SECTION 410.141
     410.141 Outpatient diabetes self-management training.
42:2.0.1.2.10.8.35.3SECTION 410.142
     410.142 CMS process for approving national accreditation organizations.
42:2.0.1.2.10.8.35.4SECTION 410.143
     410.143 Requirements for approved accreditation organizations.
42:2.0.1.2.10.8.35.5SECTION 410.144
     410.144 Quality standards for deemed entities.
42:2.0.1.2.10.8.35.6SECTION 410.145
     410.145 Requirements for entities.
42:2.0.1.2.10.8.35.7SECTION 410.146
     410.146 Diabetes outcome measurements.
42:2.0.1.2.10.9SUBPART I
Subpart I - Payment of SMI Benefits
42:2.0.1.2.10.9.35.1SECTION 410.150
     410.150 To whom payment is made.
42:2.0.1.2.10.9.35.2SECTION 410.152
     410.152 Amounts of payment.
42:2.0.1.2.10.9.35.3SECTION 410.155
     410.155 Outpatient mental health treatment limitation.
42:2.0.1.2.10.9.35.4SECTION 410.160
     410.160 Part B annual deductible.
42:2.0.1.2.10.9.35.5SECTION 410.161
     410.161 Part B blood deductible.
42:2.0.1.2.10.9.35.6SECTION 410.163
     410.163 Payment for services furnished to kidney donors.
42:2.0.1.2.10.9.35.7SECTION 410.165
     410.165 Payment for rural health clinic services and ambulatory surgical center services: Conditions.
42:2.0.1.2.10.9.35.8SECTION 410.170
     410.170 Payment for home health services, for medical and other health services furnished by a provider or an approved ESRD facility, and for comprehensive outpatient rehabilitation facility (CORF) services: Conditions.
42:2.0.1.2.10.9.35.9SECTION 410.172
     410.172 Payment for partial hospitalization services in CMHCs: Conditions.
42:2.0.1.2.10.9.35.10SECTION 410.175
     410.175 Alien absent from the United States.
42:2.0.1.2.11PART 411
PART 411 - EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
42:2.0.1.2.11.1SUBPART A
Subpart A - General Exclusions and Exclusion of Particular Services
42:2.0.1.2.11.1.35.1SECTION 411.1
     411.1 Basis and scope.
42:2.0.1.2.11.1.35.2SECTION 411.2
     411.2 Conclusive effect of QIO determinations on payment of claims.
42:2.0.1.2.11.1.35.3SECTION 411.4
     411.4 Services for which neither the beneficiary nor any other person is legally obligated to pay.
42:2.0.1.2.11.1.35.4SECTION 411.6
     411.6 Services furnished by a Federal provider of services or other Federal agency.
42:2.0.1.2.11.1.35.5SECTION 411.7
     411.7 Services that must be furnished at public expense under a Federal law or Federal Government contract.
42:2.0.1.2.11.1.35.6SECTION 411.8
     411.8 Services paid for by a Government entity.
42:2.0.1.2.11.1.35.7SECTION 411.9
     411.9 Services furnished outside the United States.
42:2.0.1.2.11.1.35.8SECTION 411.10
     411.10 Services required as a result of war.
42:2.0.1.2.11.1.35.9SECTION 411.12
     411.12 Charges imposed by an immediate relative or member of the beneficiary's household.
42:2.0.1.2.11.1.35.10SECTION 411.15
     411.15 Particular services excluded from coverage.
42:2.0.1.2.11.2SUBPART B
Subpart B - Insurance Coverage That Limits Medicare Payment: General Provisions
42:2.0.1.2.11.2.35.1SECTION 411.20
     411.20 Basis and scope.
42:2.0.1.2.11.2.35.2SECTION 411.21
     411.21 Definitions.
42:2.0.1.2.11.2.35.3SECTION 411.22
     411.22 Reimbursement obligations of primary payers and entities that received payment from primary payers.
42:2.0.1.2.11.2.35.4SECTION 411.23
     411.23 Beneficiary's cooperation.
42:2.0.1.2.11.2.35.5SECTION 411.24
     411.24 Recovery of conditional payments.
42:2.0.1.2.11.2.35.6SECTION 411.25
     411.25 Primary payer's notice of primary payment responsibility.
42:2.0.1.2.11.2.35.7SECTION 411.26
     411.26 Subrogation and right to intervene.
42:2.0.1.2.11.2.35.8SECTION 411.28
     411.28 Waiver of recovery and compromise of claims.
42:2.0.1.2.11.2.35.9SECTION 411.30
     411.30 Effect of primary payment on benefit utilization and deductibles.
42:2.0.1.2.11.2.35.10SECTION 411.31
     411.31 Authority to bill primary payers for full charges.
42:2.0.1.2.11.2.35.11SECTION 411.32
     411.32 Basis for Medicare secondary payments.
42:2.0.1.2.11.2.35.12SECTION 411.33
     411.33 Amount of Medicare secondary payment.
42:2.0.1.2.11.2.35.13SECTION 411.35
     411.35 Limitations on charges to a beneficiary or other party when a workers' compensation plan, a no-fault insurer, or an employer group health plan is primary payer.
42:2.0.1.2.11.2.35.14SECTION 411.37
     411.37 Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.
42:2.0.1.2.11.2.35.15SECTION 411.39
     411.39 Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal.
42:2.0.1.2.11.3SUBPART C
Subpart C - Limitations on Medicare Payment for Services Covered Under Workers' Compensation
42:2.0.1.2.11.3.35.1SECTION 411.40
     411.40 General provisions.
42:2.0.1.2.11.3.35.2SECTION 411.43
     411.43 Beneficiary's responsibility with respect to workers' compensation.
42:2.0.1.2.11.3.35.3SECTION 411.45
     411.45 Basis for conditional Medicare payment in workers' compensation cases.
42:2.0.1.2.11.3.35.4SECTION 411.46
     411.46 Lump-sum payments.
42:2.0.1.2.11.3.35.5SECTION 411.47
     411.47 Apportionment of a lump-sum compromise settlement of a workers' compensation claim.
42:2.0.1.2.11.4SUBPART D
Subpart D - Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance
42:2.0.1.2.11.4.35.1SECTION 411.50
     411.50 General provisions.
42:2.0.1.2.11.4.35.2SECTION 411.51
     411.51 Beneficiary's responsibility with respect to no-fault insurance.
42:2.0.1.2.11.4.35.3SECTION 411.52
     411.52 Basis for conditional Medicare payment in liability cases.
42:2.0.1.2.11.4.35.4SECTION 411.53
     411.53 Basis for conditional Medicare payment in no-fault cases.
42:2.0.1.2.11.4.35.5SECTION 411.54
     411.54 Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.
42:2.0.1.2.11.5SUBPART E
Subpart E - Limitations on Payment for Services Covered Under Group Health Plans: General Provisions
42:2.0.1.2.11.5.35.1SECTION 411.100
     411.100 Basis and scope.
42:2.0.1.2.11.5.35.2SECTION 411.101
     411.101 Definitions.
42:2.0.1.2.11.5.35.3SECTION 411.102
     411.102 Basic prohibitions and requirements.
42:2.0.1.2.11.5.35.4SECTION 411.103
     411.103 Prohibition against financial and other incentives.
42:2.0.1.2.11.5.35.5SECTION 411.104
     411.104 Current employment status.
42:2.0.1.2.11.5.35.6SECTION 411.106
     411.106 Aggregation rules.
42:2.0.1.2.11.5.35.7SECTION 411.108
     411.108 Taking into account entitlement to Medicare.
42:2.0.1.2.11.5.35.8SECTION 411.110
     411.110 Basis for determination of nonconformance.
42:2.0.1.2.11.5.35.9SECTION 411.112
     411.112 Documentation of conformance.
42:2.0.1.2.11.5.35.10SECTION 411.114
     411.114 Determination of nonconformance.
42:2.0.1.2.11.5.35.11SECTION 411.115
     411.115 Notice of determination of nonconformance.
42:2.0.1.2.11.5.35.12SECTION 411.120
     411.120 Appeals.
42:2.0.1.2.11.5.35.13SECTION 411.121
     411.121 Hearing procedures.
42:2.0.1.2.11.5.35.14SECTION 411.122
     411.122 Hearing officer's decision.
42:2.0.1.2.11.5.35.15SECTION 411.124
     411.124 Administrator's review of hearing decision.
42:2.0.1.2.11.5.35.16SECTION 411.126
     411.126 Reopening of determinations and decisions.
42:2.0.1.2.11.5.35.17SECTION 411.130
     411.130 Referral to Internal Revenue Service (IRS).
42:2.0.1.2.11.6SUBPART F
Subpart F - Special Rules: Individuals Eligible or Entitled on the Basis of ESRD, Who Are Also Covered Under Group Health Plans
42:2.0.1.2.11.6.35.1SECTION 411.160
     411.160 Scope.
42:2.0.1.2.11.6.35.2SECTION 411.161
     411.161 Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.
42:2.0.1.2.11.6.35.3SECTION 411.162
     411.162 Medicare benefits secondary to group health plan benefits.
42:2.0.1.2.11.6.35.4SECTION 411.163
     411.163 Coordination of benefits: Dual entitlement situations.
42:2.0.1.2.11.6.35.5SECTION 411.165
     411.165 Basis for conditional Medicare payments.
42:2.0.1.2.11.7SUBPART G
Subpart G - Special Rules: Aged Beneficiaries and Spouses Who Are Also Covered Under Group Health Plans
42:2.0.1.2.11.7.35.1SECTION 411.170
     411.170 General provisions.
42:2.0.1.2.11.7.35.2SECTION 411.172
     411.172 Medicare benefits secondary to group health plan benefits.
42:2.0.1.2.11.7.35.3SECTION 411.175
     411.175 Basis for Medicare primary payments.
42:2.0.1.2.11.8SUBPART H
Subpart H - Special Rules: Disabled Beneficiaries Who Are Also Covered Under Large Group Health Plans
42:2.0.1.2.11.8.35.1SECTION 411.200
     411.200 Basis.
42:2.0.1.2.11.8.35.2SECTION 411.201
     411.201 Definitions.
42:2.0.1.2.11.8.35.3SECTION 411.204
     411.204 Medicare benefits secondary to LGHP benefits.
42:2.0.1.2.11.8.35.4SECTION 411.206
     411.206 Basis for Medicare primary payments and limits on secondary payments.
42:2.0.1.2.11.9SUBPART I
Subpart I [Reserved]
42:2.0.1.2.11.10SUBPART J
Subpart J - Financial Relationships Between Physicians and Entities Furnishing Designated Health Services
42:2.0.1.2.11.10.35.1SECTION 411.350
     411.350 Scope of subpart.
42:2.0.1.2.11.10.35.2SECTION 411.351
     411.351 Definitions.
42:2.0.1.2.11.10.35.3SECTION 411.352
     411.352 Group practice.
42:2.0.1.2.11.10.35.4SECTION 411.353
     411.353 Prohibition on certain referrals by physicians and limitations on billing.
42:2.0.1.2.11.10.35.5SECTION 411.354
     411.354 Financial relationship, compensation, and ownership or investment interest.
42:2.0.1.2.11.10.35.6SECTION 411.355
     411.355 General exceptions to the referral prohibition related to both ownership/investment and compensation.
42:2.0.1.2.11.10.35.7SECTION 411.356
     411.356 Exceptions to the referral prohibition related to ownership or investment interests.
42:2.0.1.2.11.10.35.8SECTION 411.357
     411.357 Exceptions to the referral prohibition related to compensation arrangements.
42:2.0.1.2.11.10.35.9SECTION 411.361
     411.361 Reporting requirements.
42:2.0.1.2.11.10.35.10SECTION 411.362
     411.362 Additional requirements concerning physician ownership and investment in hospitals.
42:2.0.1.2.11.10.35.11SECTION 411.370
     411.370 Advisory opinions relating to physician referrals.
42:2.0.1.2.11.10.35.12SECTION 411.372
     411.372 Procedure for submitting a request.
42:2.0.1.2.11.10.35.13SECTION 411.373
     411.373 Certification.
42:2.0.1.2.11.10.35.14SECTION 411.375
     411.375 Fees for the cost of advisory opinions.
42:2.0.1.2.11.10.35.15SECTION 411.377
     411.377 Expert opinions from outside sources.
42:2.0.1.2.11.10.35.16SECTION 411.378
     411.378 Withdrawing a request.
42:2.0.1.2.11.10.35.17SECTION 411.379
     411.379 When CMS accepts a request.
42:2.0.1.2.11.10.35.18SECTION 411.380
     411.380 When CMS issues a formal advisory opinion.
42:2.0.1.2.11.10.35.19SECTION 411.382
     411.382 CMS' right to rescind advisory opinions.
42:2.0.1.2.11.10.35.20SECTION 411.384
     411.384 Disclosing advisory opinions and supporting information.
42:2.0.1.2.11.10.35.21SECTION 411.386
     411.386 CMS's advisory opinions as exclusive.
42:2.0.1.2.11.10.35.22SECTION 411.387
     411.387 Effect of an advisory opinion.
42:2.0.1.2.11.10.35.23SECTION 411.388
     411.388 When advisory opinions are not admissible evidence.
42:2.0.1.2.11.10.35.24SECTION 411.389
     411.389 Range of the advisory opinion.
42:2.0.1.2.11.11SUBPART K
Subpart K - Payment for Certain Excluded Services
42:2.0.1.2.11.11.35.1SECTION 411.400
     411.400 Payment for custodial care and services not reasonable and necessary.
42:2.0.1.2.11.11.35.2SECTION 411.402
     411.402 Indemnification of beneficiary.
42:2.0.1.2.11.11.35.3SECTION 411.404
     411.404 Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
42:2.0.1.2.11.11.35.4SECTION 411.406
     411.406 Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
42:2.0.1.2.11.11.35.5SECTION 411.408
     411.408 Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.
42:2.0.1.2.12PART 412
PART 412 - PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
42:2.0.1.2.12.1SUBPART A
Subpart A - General Provisions
42:2.0.1.2.12.1.47.1SECTION 412.1
     412.1 Scope of part.
42:2.0.1.2.12.1.47.2SECTION 412.2
     412.2 Basis of payment.
42:2.0.1.2.12.1.47.3SECTION 412.3
     412.3 Admissions.
42:2.0.1.2.12.1.47.4SECTION 412.4
     412.4 Discharges and transfers.
42:2.0.1.2.12.1.47.5SECTION 412.6
     412.6 Cost reporting periods subject to the prospective payment systems.
42:2.0.1.2.12.1.47.6SECTION 412.8
     412.8 Publication of schedules for determining prospective payment rates.
42:2.0.1.2.12.1.47.7SECTION 412.10
     412.10 Changes in the DRG classification system.
42:2.0.1.2.12.2SUBPART B
Subpart B - Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
42:2.0.1.2.12.2.47.1SECTION 412.20
     412.20 Hospital services subject to the prospective payment systems.
42:2.0.1.2.12.2.47.2SECTION 412.22
     412.22 Excluded hospitals and hospital units: General rules.
42:2.0.1.2.12.2.47.3SECTION 412.23
     412.23 Excluded hospitals: Classifications.
42:2.0.1.2.12.2.47.4SECTION 412.25
     412.25 Excluded hospital units: Common requirements.
42:2.0.1.2.12.2.47.5SECTION 412.27
     412.27 Excluded psychiatric units: Additional requirements.
42:2.0.1.2.12.2.47.6SECTION 412.29
     412.29 Classification criteria for payment under the inpatient rehabilitation facility prospective payment system.
42:2.0.1.2.12.2.47.7SECTION 412.30
     412.30 [Reserved]
42:2.0.1.2.12.3SUBPART C
Subpart C - Conditions for Payment Under the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
42:2.0.1.2.12.3.47.1SECTION 412.40
     412.40 General requirements.
42:2.0.1.2.12.3.47.2SECTION 412.42
     412.42 Limitations on charges to beneficiaries.
42:2.0.1.2.12.3.47.3SECTION 412.44
     412.44 Medical review requirements: Admissions and quality review.
42:2.0.1.2.12.3.47.4SECTION 412.46
     412.46 Medical review requirements.
42:2.0.1.2.12.3.47.5SECTION 412.48
     412.48 Denial of payment as a result of admissions and quality review.
42:2.0.1.2.12.3.47.6SECTION 412.50
     412.50 Furnishing of inpatient hospital services directly or under arrangements.
42:2.0.1.2.12.3.47.7SECTION 412.52
     412.52 Reporting and recordkeeping requirements.
42:2.0.1.2.12.4SUBPART D
Subpart D - Basic Methodology for Determining Prospective Payment Federal Rates for Inpatient Operating Costs
42:2.0.1.2.12.4.47.1SECTION 412.60
     412.60 DRG classification and weighting factors.
42:2.0.1.2.12.4.47.2SECTION 412.62
     412.62 Federal rates for inpatient operating costs for fiscal year 1984.
42:2.0.1.2.12.4.47.3SECTION 412.63
     412.63 Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004.
42:2.0.1.2.12.4.47.4SECTION 412.64
     412.64 Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.
42:2.0.1.2.12.5SUBPART E
Subpart E - Determination of Transition Period Payment Rates for the Prospective Payment System for Inpatient Operating Costs
42:2.0.1.2.12.5.47.1SECTION 412.70
     412.70 General description.
42:2.0.1.2.12.5.47.2SECTION 412.71
     412.71 Determination of base-year inpatient operating costs.
42:2.0.1.2.12.5.47.3SECTION 412.72
     412.72 Modification of base-year costs.
42:2.0.1.2.12.5.47.4SECTION 412.73
     412.73 Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.
42:2.0.1.2.12.5.47.5SECTION 412.75
     412.75 Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.
42:2.0.1.2.12.5.47.6SECTION 412.76
     412.76 Recovery of excess transition period payment amounts resulting from unlawful claims.
42:2.0.1.2.12.5.47.7SECTION 412.77
     412.77 Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 1996 base period.
42:2.0.1.2.12.5.47.8SECTION 412.78
     412.78 Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 2006 base period.
42:2.0.1.2.12.5.47.9SECTION 412.79
     412.79 Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period.
42:2.0.1.2.12.6SUBPART F
Subpart F - Payments for Outlier Cases, Special Treatment Payment for New Technology, and Payment Adjustment for Certain Replaced Devices
42:2.0.1.2.12.6.47SUBJGRP 47
  Payment for Outlier Cases
42:2.0.1.2.12.6.47.1SECTION 412.80
     412.80 Outlier cases: General provisions.
42:2.0.1.2.12.6.47.2SECTION 412.82
     412.82 Payment for extended length-of-stay cases (day outliers).
42:2.0.1.2.12.6.47.3SECTION 412.84
     412.84 Payment for extraordinarily high-cost cases (cost outliers).
42:2.0.1.2.12.6.47.4SECTION 412.86
     412.86 Payment for extraordinarily high-cost day outliers.
42:2.0.1.2.12.6.48SUBJGRP 48
  Additional Special Payment for Certain New Technology
42:2.0.1.2.12.6.48.5SECTION 412.87
     412.87 Additional payment for new medical services and technologies: General provisions.
42:2.0.1.2.12.6.48.6SECTION 412.88
     412.88 Additional payment for new medical service or technology.
42:2.0.1.2.12.6.49SUBJGRP 49
  Payment Adjustment for Certain Replaced Devices
42:2.0.1.2.12.6.49.7SECTION 412.89
     412.89 Payment adjustment for certain replaced devices.
42:2.0.1.2.12.7SUBPART G
Subpart G - Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs
42:2.0.1.2.12.7.50.1SECTION 412.90
     412.90 General rules.
42:2.0.1.2.12.7.50.2SECTION 412.92
     412.92 Special treatment: Sole community hospitals.
42:2.0.1.2.12.7.50.3SECTION 412.96
     412.96 Special treatment: Referral centers.
42:2.0.1.2.12.7.50.4SECTION 412.98
     412.98 [Reserved]
42:2.0.1.2.12.7.50.5SECTION 412.100
     412.100 Special treatment: Renal transplantation centers.
42:2.0.1.2.12.7.50.6SECTION 412.101
     412.101 Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.
42:2.0.1.2.12.7.50.7SECTION 412.102
     412.102 Special treatment: Hospitals located in areas that are changing from urban to rural as a result of a geographic redesignation.
42:2.0.1.2.12.7.50.8SECTION 412.103
     412.103 Special treatment: Hospitals located in urban areas and that apply for reclassification as rural.
42:2.0.1.2.12.7.50.9SECTION 412.104
     412.104 Special treatment: Hospitals with high percentage of ESRD discharges.
42:2.0.1.2.12.7.50.10SECTION 412.105
     412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
42:2.0.1.2.12.7.50.11SECTION 412.106
     412.106 Special treatment: Hospitals that serve a disproportionate share of low-income patients.
42:2.0.1.2.12.7.50.12SECTION 412.107
     412.107 Special treatment: Hospitals that receive an additional update for FYs 1998 and 1999.
42:2.0.1.2.12.7.50.13SECTION 412.108
     412.108 Special treatment: Medicare-dependent, small rural hospitals.
42:2.0.1.2.12.7.50.14SECTION 412.109
     412.109 Special treatment: Essential access community hospitals (EACHs).
42:2.0.1.2.12.8SUBPART H
Subpart H - Payments to Hospitals Under the Prospective Payment Systems
42:2.0.1.2.12.8.50.1SECTION 412.110
     412.110 Total Medicare payment.
42:2.0.1.2.12.8.50.2SECTION 412.112
     412.112 Payments determined on a per case basis.
42:2.0.1.2.12.8.50.3SECTION 412.113
     412.113 Other payments.
42:2.0.1.2.12.8.50.4SECTION 412.115
     412.115 Additional payments.
42:2.0.1.2.12.8.50.5SECTION 412.116
     412.116 Method of payment.
42:2.0.1.2.12.8.50.6SECTION 412.120
     412.120 Reductions to total payments.
42:2.0.1.2.12.8.50.7SECTION 412.125
     412.125 Effect of change of ownership on payments under the prospective payment systems.
42:2.0.1.2.12.8.50.8SECTION 412.130
     412.130 Retroactive adjustments for incorrectly excluded hospitals and units.
42:2.0.1.2.12.8.50.9SECTION 412.140
     412.140 Participation, data submission, and validation requirements under the Hospital Inpatient Quality Reporting (IQR) Program.
42:2.0.1.2.12.9SUBPART I
Subpart I - Adjustments to the Base Operating DRG Payment Amounts Under the Prospective Payment Systems for Inpatient Operating Costs
42:2.0.1.2.12.9.50SUBJGRP 50
  Payment Adjustments Under the Hospital Readmissions Reduction Program
42:2.0.1.2.12.9.50.1SECTION 412.150
     412.150 Basis and scope of subpart.
42:2.0.1.2.12.9.50.2SECTION 412.152
     412.152 Definitions for the Hospital Readmissions Reduction Program.
42:2.0.1.2.12.9.50.3SECTION 412.154
     412.154 Payment adjustments under the Hospital Readmissions Reduction Program.
42:2.0.1.2.12.9.50.4SECTION 412.155-412.159
     412.155-412.159 [Reserved]
42:2.0.1.2.12.9.51SUBJGRP 51
  Incentive Payments Under the Hospital Value-Based Purchasing Program
42:2.0.1.2.12.9.51.5SECTION 412.160
     412.160 Definitions for the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.12.9.51.6SECTION 412.161
     412.161 Applicability of the Hospital Value-Based Purchasing (VBP) Program
42:2.0.1.2.12.9.51.7SECTION 412.162
     412.162 Process for reducing the base operating DRG payment amount and applying the value-based incentive payment amount adjustment under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.12.9.51.8SECTION 412.163
     412.163 Process for making hospital-specific performance information under the Hospital Value-Based Purchasing (VBP) Program available to the public.
42:2.0.1.2.12.9.51.9SECTION 412.164
     412.164 Measure selection under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.12.9.51.10SECTION 412.165
     412.165 Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.12.9.51.11SECTION 412.167
     412.167 Appeal under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.12.9.51.12SECTION 412.168-412.169
     412.168-412.169 [Reserved]
42:2.0.1.2.12.9.52SUBJGRP 52
  Payment Adjustments Under the Hospital-Acquired Condition Reduction Program
42:2.0.1.2.12.9.52.13SECTION 412.170
     412.170 Definitions for the Hospital-Acquired Condition Reduction Program.
42:2.0.1.2.12.9.52.14SECTION 412.172
     412.172 Payment adjustments under the Hospital-Acquired Condition Reduction Program.
42:2.0.1.2.12.10SUBPART J
Subpart J [Reserved]
42:2.0.1.2.12.11SUBPART K
Subpart K - Prospective Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico
42:2.0.1.2.12.11.53.1SECTION 412.200
     412.200 General provisions.
42:2.0.1.2.12.11.53.2SECTION 412.204
     412.204 Payment to hospitals located in Puerto Rico.
42:2.0.1.2.12.11.53.3SECTION 412.208
     412.208 Puerto Rico rates for Federal fiscal year 1988.
42:2.0.1.2.12.11.53.4SECTION 412.210
     412.210 Puerto Rico rates for Federal fiscal years 1989 through 2003.
42:2.0.1.2.12.11.53.5SECTION 412.211
     412.211 Puerto Rico rates for Federal fiscal year 2004 and subsequent fiscal years.
42:2.0.1.2.12.11.53.6SECTION 412.212
     412.212 National rate.
42:2.0.1.2.12.11.53.7SECTION 412.220
     412.220 Special treatment of certain hospitals located in Puerto Rico.
42:2.0.1.2.12.12SUBPART L
Subpart L - The Medicare Geographic Classification Review Board
42:2.0.1.2.12.12.53SUBJGRP 53
  Criteria and Conditions for Redesignation
42:2.0.1.2.12.12.53.1SECTION 412.230
     412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
42:2.0.1.2.12.12.53.2SECTION 412.232
     412.232 Criteria for all hospitals in a rural county seeking urban redesignation.
42:2.0.1.2.12.12.53.3SECTION 412.234
     412.234 Criteria for all hospitals in an urban county seeking redesignation to another urban area.
42:2.0.1.2.12.12.53.4SECTION 412.235
     412.235 Criteria for all hospitals in a State seeking a statewide wage index redesignation.
42:2.0.1.2.12.12.54SUBJGRP 54
  Composition and Procedures
42:2.0.1.2.12.12.54.5SECTION 412.246
     412.246 MGCRB members.
42:2.0.1.2.12.12.54.6SECTION 412.248
     412.248 Number of members needed for a decision or a hearing.
42:2.0.1.2.12.12.54.7SECTION 412.250
     412.250 Sources of MGCRB's authority.
42:2.0.1.2.12.12.54.8SECTION 412.252
     412.252 Applications.
42:2.0.1.2.12.12.54.9SECTION 412.254
     412.254 Proceedings before MGCRB.
42:2.0.1.2.12.12.54.10SECTION 412.256
     412.256 Application requirements.
42:2.0.1.2.12.12.54.11SECTION 412.258
     412.258 Parties to MGCRB proceeding.
42:2.0.1.2.12.12.54.12SECTION 412.260
     412.260 Time and place of the oral hearing.
42:2.0.1.2.12.12.54.13SECTION 412.262
     412.262 Disqualification of an MGCRB member.
42:2.0.1.2.12.12.54.14SECTION 412.264
     412.264 Evidence and comments in MGCRB proceeding.
42:2.0.1.2.12.12.54.15SECTION 412.266
     412.266 Availability of wage data.
42:2.0.1.2.12.12.54.16SECTION 412.268
     412.268 Subpoenas.
42:2.0.1.2.12.12.54.17SECTION 412.270
     412.270 Witnesses.
42:2.0.1.2.12.12.54.18SECTION 412.272
     412.272 Record of proceedings before the MGCRB.
42:2.0.1.2.12.12.54.19SECTION 412.273
     412.273 Withdrawing an application, terminating an approved 3-year reclassification, or canceling a previous withdrawal or termination.
42:2.0.1.2.12.12.54.20SECTION 412.274
     412.274 Scope and effect of an MGCRB decision.
42:2.0.1.2.12.12.54.21SECTION 412.276
     412.276 Timing of MGCRB decision and its appeal.
42:2.0.1.2.12.12.54.22SECTION 412.278
     412.278 Administrator's review.
42:2.0.1.2.12.12.54.23SECTION 412.280
     412.280 Representation.
42:2.0.1.2.12.13SUBPART M
Subpart M - Prospective Payment System for Inpatient Hospital Capital Costs
42:2.0.1.2.12.13.55SUBJGRP 55
  General Provisions
42:2.0.1.2.12.13.55.1SECTION 412.300
     412.300 Scope of subpart and definition.
42:2.0.1.2.12.13.55.2SECTION 412.302
     412.302 Introduction to capital costs.
42:2.0.1.2.12.13.55.3SECTION 412.304
     412.304 Implementation of the capital prospective payment system.
42:2.0.1.2.12.13.56SUBJGRP 56
  Basic Methodology for Determining the Federal Rate for Capital-Related Costs
42:2.0.1.2.12.13.56.4SECTION 412.308
     412.308 Determining and updating the Federal rate.
42:2.0.1.2.12.13.56.5SECTION 412.312
     412.312 Payment based on the Federal rate.
42:2.0.1.2.12.13.56.6SECTION 412.316
     412.316 Geographic adjustment factors.
42:2.0.1.2.12.13.56.7SECTION 412.320
     412.320 Disproportionate share adjustment factor.
42:2.0.1.2.12.13.56.8SECTION 412.322
     412.322 Indirect medical education adjustment factor.
42:2.0.1.2.12.13.57SUBJGRP 57
  Determination of Transition Period Payment Rates for Capital-Related Costs
42:2.0.1.2.12.13.57.9SECTION 412.324
     412.324 General description.
42:2.0.1.2.12.13.57.10SECTION 412.328
     412.328 Determining and updating the hospital-specific rate.
42:2.0.1.2.12.13.57.11SECTION 412.331
     412.331 Determining hospital-specific rates in cases of hospital merger, consolidation, or dissolution.
42:2.0.1.2.12.13.57.12SECTION 412.332
     412.332 Payment based on the hospital-specific rate.
42:2.0.1.2.12.13.57.13SECTION 412.336
     412.336 Transition period payment methodologies.
42:2.0.1.2.12.13.57.14SECTION 412.340
     412.340 Fully prospective payment methodology.
42:2.0.1.2.12.13.57.15SECTION 412.344
     412.344 Hold-harmless payment methodology.
42:2.0.1.2.12.13.57.16SECTION 412.348
     412.348 Exception payments.
42:2.0.1.2.12.13.57.17SECTION 412.352
     412.352 Budget neutrality adjustment.
42:2.0.1.2.12.13.58SUBJGRP 58
  Special Rules for Puerto Rico Hospitals
42:2.0.1.2.12.13.58.18SECTION 412.370
     412.370 General provisions for hospitals located in Puerto Rico.
42:2.0.1.2.12.13.58.19SECTION 412.374
     412.374 Payments to hospitals located in Puerto Rico.
42:2.0.1.2.12.14SUBPART N
Subpart N - Prospective Payment System for Inpatient Hospital Services of Inpatient Psychiatric Facilities
42:2.0.1.2.12.14.59.1SECTION 412.400
     412.400 Basis and scope of subpart.
42:2.0.1.2.12.14.59.2SECTION 412.402
     412.402 Definitions.
42:2.0.1.2.12.14.59.3SECTION 412.404
     412.404 Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities.
42:2.0.1.2.12.14.59.4SECTION 412.405
     412.405 Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system.
42:2.0.1.2.12.14.59.5SECTION 412.422
     412.422 Basis of payment.
42:2.0.1.2.12.14.59.6SECTION 412.424
     412.424 Methodology for calculating the Federal per diem payment amount.
42:2.0.1.2.12.14.59.7SECTION 412.426
     412.426 Transition period.
42:2.0.1.2.12.14.59.8SECTION 412.428
     412.428 Publication of changes to the inpatient psychiatric facility prospective payment system.
42:2.0.1.2.12.14.59.9SECTION 412.432
     412.432 Method of payment under the inpatient psychiatric facility prospective payment system.
42:2.0.1.2.12.14.59.10SECTION 412.434
     412.434 Reconsideration and appeals procedures of Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program decisions.
42:2.0.1.2.12.15SUBPART O
Subpart O - Prospective Payment System for Long-Term Care Hospitals
42:2.0.1.2.12.15.59.1SECTION 412.500
     412.500 Basis and scope of subpart.
42:2.0.1.2.12.15.59.2SECTION 412.503
     412.503 Definitions.
42:2.0.1.2.12.15.59.3SECTION 412.505
     412.505 Conditions for payment under the prospective payment system for long-term care hospitals.
42:2.0.1.2.12.15.59.4SECTION 412.507
     412.507 Limitation on charges to beneficiaries.
42:2.0.1.2.12.15.59.5SECTION 412.508
     412.508 Medical review requirements.
42:2.0.1.2.12.15.59.6SECTION 412.509
     412.509 Furnishing of inpatient hospital services directly or under arrangement.
42:2.0.1.2.12.15.59.7SECTION 412.511
     412.511 Reporting and recordkeeping requirements.
42:2.0.1.2.12.15.59.8SECTION 412.513
     412.513 Patient classification system.
42:2.0.1.2.12.15.59.9SECTION 412.515
     412.515 LTC-DRG weighting factors.
42:2.0.1.2.12.15.59.10SECTION 412.517
     412.517 Revision of LTC-DRG group classifications and weighting factors.
42:2.0.1.2.12.15.59.11SECTION 412.521
     412.521 Basis of payment.
42:2.0.1.2.12.15.59.12SECTION 412.522
     412.522 Application of site neutral payment rate.
42:2.0.1.2.12.15.59.13SECTION 412.523
     412.523 Methodology for calculating the Federal prospective payment rates.
42:2.0.1.2.12.15.59.14SECTION 412.525
     412.525 Adjustments to the Federal prospective payment.
42:2.0.1.2.12.15.59.15SECTION 412.526
     412.526 Payment provisions for a “subclause (II)” long-term care hospital.
42:2.0.1.2.12.15.59.16SECTION 412.529
     412.529 Special payment provision for short-stay outliers.
42:2.0.1.2.12.15.59.17SECTION 412.531
     412.531 Special payment provisions when an interruption of a stay occurs in a long-term care hospital.
42:2.0.1.2.12.15.59.18SECTION 412.533
     412.533 Transition payments.
42:2.0.1.2.12.15.59.19SECTION 412.534
     412.534 Special payment provisions for long-term care hospitals-within-hospitals and satellites of long-term care hospitals, effective for discharges occurring in cost reporting periods beginning on or before September 30, 2016.
42:2.0.1.2.12.15.59.20SECTION 412.535
     412.535 Publication of the Federal prospective payment rates.
42:2.0.1.2.12.15.59.21SECTION 412.536
     412.536 Special payment provisions for long-term care hospitals and satellites of long-term care hospitals that discharge Medicare patients admitted from a hospital not located in the same building or on the same campus as the long-term care hospital or sa
42:2.0.1.2.12.15.59.22SECTION 412.538
     412.538 [Reserved]
42:2.0.1.2.12.15.59.23SECTION 412.540
     412.540 Method of payment for preadmission services under the long-term care hospital prospective payment system.
42:2.0.1.2.12.15.59.24SECTION 412.541
     412.541 Method of payment under the long-term care hospital prospective payment system.
42:2.0.1.2.12.15.59.25SECTION 412.560
     412.560 Requirements under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).
42:2.0.1.2.12.16SUBPART P
Subpart P - Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
42:2.0.1.2.12.16.59.1SECTION 412.600
     412.600 Basis and scope of subpart.
42:2.0.1.2.12.16.59.2SECTION 412.602
     412.602 Definitions.
42:2.0.1.2.12.16.59.3SECTION 412.604
     412.604 Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.
42:2.0.1.2.12.16.59.4SECTION 412.606
     412.606 Patient assessments.
42:2.0.1.2.12.16.59.5SECTION 412.608
     412.608 Patients' rights regarding the collection of patient assessment data.
42:2.0.1.2.12.16.59.6SECTION 412.610
     412.610 Assessment schedule.
42:2.0.1.2.12.16.59.7SECTION 412.612
     412.612 Coordination of the collection of patient assessment data.
42:2.0.1.2.12.16.59.8SECTION 412.614
     412.614 Transmission of patient assessment data.
42:2.0.1.2.12.16.59.9SECTION 412.616
     412.616 Release of information collected using the patient assessment instrument.
42:2.0.1.2.12.16.59.10SECTION 412.618
     412.618 Assessment process for interrupted stays.
42:2.0.1.2.12.16.59.11SECTION 412.620
     412.620 Patient classification system.
42:2.0.1.2.12.16.59.12SECTION 412.622
     412.622 Basis of payment.
42:2.0.1.2.12.16.59.13SECTION 412.624
     412.624 Methodology for calculating the Federal prospective payment rates.
42:2.0.1.2.12.16.59.14SECTION 412.626
     412.626 Transition period.
42:2.0.1.2.12.16.59.15SECTION 412.628
     412.628 Publication of the Federal prospective payment rates.
42:2.0.1.2.12.16.59.16SECTION 412.630
     412.630 Limitation on review.
42:2.0.1.2.12.16.59.17SECTION 412.632
     412.632 Method of payment under the inpatient rehabilitation facility prospective payment system.
42:2.0.1.2.12.16.59.18SECTION 412.634
     412.634 Requirements under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP).
42:2.0.1.2.13PART 413
PART 413 - PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES; PAYMENT FOR ACUTE KIDNEY INJURY DIALYSIS
42:2.0.1.2.13.1SUBPART A
Subpart A - Introduction and General Rules
42:2.0.1.2.13.1.59.1SECTION 413.1
     413.1 Introduction.
42:2.0.1.2.13.1.59.2SECTION 413.5
     413.5 Cost reimbursement: General.
42:2.0.1.2.13.1.59.3SECTION 413.9
     413.9 Cost related to patient care.
42:2.0.1.2.13.1.59.4SECTION 413.13
     413.13 Amount of payment if customary charges for services furnished are less than reasonable costs.
42:2.0.1.2.13.1.59.5SECTION 413.17
     413.17 Cost to related organizations.
42:2.0.1.2.13.2SUBPART B
Subpart B - Accounting Records and Reports
42:2.0.1.2.13.2.59.1SECTION 413.20
     413.20 Financial data and reports.
42:2.0.1.2.13.2.59.2SECTION 413.24
     413.24 Adequate cost data and cost finding.
42:2.0.1.2.13.3SUBPART C
Subpart C - Limits on Cost Reimbursement
42:2.0.1.2.13.3.59.1SECTION 413.30
     413.30 Limitations on payable costs.
42:2.0.1.2.13.3.59.2SECTION 413.35
     413.35 Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.
42:2.0.1.2.13.3.59.3SECTION 413.40
     413.40 Ceiling on the rate of increase in hospital inpatient costs.
42:2.0.1.2.13.4SUBPART D
Subpart D - Apportionment
42:2.0.1.2.13.4.59.1SECTION 413.50
     413.50 Apportionment of allowable costs.
42:2.0.1.2.13.4.59.2SECTION 413.53
     413.53 Determination of cost of services to beneficiaries.
42:2.0.1.2.13.4.59.3SECTION 413.56
     413.56 [Reserved]
42:2.0.1.2.13.5SUBPART E
Subpart E - Payments to Providers
42:2.0.1.2.13.5.59.1SECTION 413.60
     413.60 Payments to providers: General.
42:2.0.1.2.13.5.59.2SECTION 413.64
     413.64 Payments to providers: Specific rules.
42:2.0.1.2.13.5.59.3SECTION 413.65
     413.65 Requirements for a determination that a facility or an organization has provider-based status.
42:2.0.1.2.13.5.59.4SECTION 413.70
     413.70 Payment for services of a CAH.
42:2.0.1.2.13.5.59.5SECTION 413.74
     413.74 Payment to a foreign hospital.
42:2.0.1.2.13.6SUBPART F
Subpart F - Specific Categories of Costs
42:2.0.1.2.13.6.59.1SECTION 413.75
     413.75 Direct GME payments: General requirements.
42:2.0.1.2.13.6.59.2SECTION 413.76
     413.76 Direct GME payments: Calculation of payments for GME costs.
42:2.0.1.2.13.6.59.3SECTION 413.77
     413.77 Direct GME payments: Determination of per resident amounts.
42:2.0.1.2.13.6.59.4SECTION 413.78
     413.78 Direct GME payments: Determination of the total number of FTE residents.
42:2.0.1.2.13.6.59.5SECTION 413.79
     413.79 Direct GME payments: Determination of the weighted number of FTE residents.
42:2.0.1.2.13.6.59.6SECTION 413.80
     413.80 Direct GME payments: Determination of weighting factors for foreign medical graduates.
42:2.0.1.2.13.6.59.7SECTION 413.81
     413.81 Direct GME payments: Application of community support and redistribution of costs in determining FTE resident counts.
42:2.0.1.2.13.6.59.8SECTION 413.82
     413.82 Direct GME payments: Special rules for States that formerly had a waiver from Medicare reimbursement principles.
42:2.0.1.2.13.6.59.9SECTION 413.83
     413.83 Direct GME payments: Adjustment of a hospital's target amount or prospective payment hospital-specific rate.
42:2.0.1.2.13.6.59.10SECTION 413.85
     413.85 Cost of approved nursing and allied health education activities.
42:2.0.1.2.13.6.59.11SECTION 413.87
     413.87 Payments for Medicare + Choice nursing and allied health education programs.
42:2.0.1.2.13.6.59.12SECTION 413.88
     413.88 Incentive payments under plans for voluntary reduction in number of medical residents.
42:2.0.1.2.13.6.59.13SECTION 413.89
     413.89 Bad debts, charity, and courtesy allowances.
42:2.0.1.2.13.6.59.14SECTION 413.90
     413.90 Research costs.
42:2.0.1.2.13.6.59.15SECTION 413.92
     413.92 Costs of surety bonds.
42:2.0.1.2.13.6.59.16SECTION 413.94
     413.94 Value of services of nonpaid workers.
42:2.0.1.2.13.6.59.17SECTION 413.98
     413.98 Purchase discounts and allowances, and refunds of expenses.
42:2.0.1.2.13.6.59.18SECTION 413.100
     413.100 Special treatment of certain accrued costs.
42:2.0.1.2.13.6.59.19SECTION 413.102
     413.102 Compensation of owners.
42:2.0.1.2.13.6.59.20SECTION 413.106
     413.106 Reasonable cost of physical and other therapy services furnished under arrangements.
42:2.0.1.2.13.6.59.21SECTION 413.114
     413.114 Payment for posthospital SNF care furnished by a swing-bed hospital.
42:2.0.1.2.13.6.59.22SECTION 413.118
     413.118 Payment for facility services related to covered ASC surgical procedures performed in hospitals on an outpatient basis.
42:2.0.1.2.13.6.59.23SECTION 413.122
     413.122 Payment for hospital outpatient radiology services and other diagnostic procedures.
42:2.0.1.2.13.6.59.24SECTION 413.123
     413.123 Payment for screening mammography performed by hospitals on an outpatient basis.
42:2.0.1.2.13.6.59.25SECTION 413.124
     413.124 Reduction to hospital outpatient operating costs.
42:2.0.1.2.13.6.59.26SECTION 413.125
     413.125 Payment for home health agency services.
42:2.0.1.2.13.7SUBPART G
Subpart G - Capital-Related Costs
42:2.0.1.2.13.7.59.1SECTION 413.130
     413.130 Introduction to capital-related costs.
42:2.0.1.2.13.7.59.2SECTION 413.134
     413.134 Depreciation: Allowance for depreciation based on asset costs.
42:2.0.1.2.13.7.59.3SECTION 413.139
     413.139 Depreciation: Optional allowance for depreciation based on a percentage of operating costs.
42:2.0.1.2.13.7.59.4SECTION 413.144
     413.144 Depreciation: Allowance for depreciation on fully depreciated or partially depreciated assets.
42:2.0.1.2.13.7.59.5SECTION 413.149
     413.149 Depreciation: Allowance for depreciation on assets financed with Federal or public funds.
42:2.0.1.2.13.7.59.6SECTION 413.153
     413.153 Interest expense.
42:2.0.1.2.13.7.59.7SECTION 413.157
     413.157 Return on equity capital of proprietary providers.
42:2.0.1.2.13.8SUBPART H
Subpart H - Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs
42:2.0.1.2.13.8.59.1SECTION 413.170
     413.170 Scope.
42:2.0.1.2.13.8.59.2SECTION 413.171
     413.171 Definitions.
42:2.0.1.2.13.8.59.3SECTION 413.172
     413.172 Principles of prospective payment.
42:2.0.1.2.13.8.59.4SECTION 413.174
     413.174 Prospective rates for hospital-based and independent ESRD facilities.
42:2.0.1.2.13.8.59.5SECTION 413.176
     413.176 Amount of payments.
42:2.0.1.2.13.8.59.6SECTION 413.177
     413.177 Quality incentive program payment.
42:2.0.1.2.13.8.59.7SECTION 413.178
     413.178 ESRD quality incentive program.
42:2.0.1.2.13.8.59.8SECTION 413.180
     413.180 Procedures for requesting exceptions to payment rates.
42:2.0.1.2.13.8.59.9SECTION 413.182
     413.182 Criteria for approval of exception requests.
42:2.0.1.2.13.8.59.10SECTION 413.184
     413.184 Payment exception: Pediatric patient mix.
42:2.0.1.2.13.8.59.11SECTION 413.186
     413.186 Payment exception: Self-dialysis training costs in pediatric facilities.
42:2.0.1.2.13.8.59.12SECTION 413.194
     413.194 Appeals.
42:2.0.1.2.13.8.59.13SECTION 413.195
     413.195 Limitation on Review.
42:2.0.1.2.13.8.59.14SECTION 413.196
     413.196 Notification of changes in rate-setting methodologies and payment rates.
42:2.0.1.2.13.8.59.15SECTION 413.198
     413.198 Recordkeeping and cost reporting requirements for outpatient maintenance dialysis.
42:2.0.1.2.13.8.59.16SECTION 413.200
     413.200 Payment of independent organ procurement organizations and histocompatibility laboratories.
42:2.0.1.2.13.8.59.17SECTION 413.202
     413.202 Organ procurement organization (OPO) cost for kidneys sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
42:2.0.1.2.13.8.59.18SECTION 413.203
     413.203 Transplant center costs for organs sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
42:2.0.1.2.13.8.59.19SECTION 413.210
     413.210 Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.
42:2.0.1.2.13.8.59.20SECTION 413.215
     413.215 Basis of payment.
42:2.0.1.2.13.8.59.21SECTION 413.217
     413.217 Items and services included in the ESRD prospective payment system.
42:2.0.1.2.13.8.59.22SECTION 413.220
     413.220 Methodology for calculating the per-treatment base rate under the ESRD prospective payment system effective January 1, 2011.
42:2.0.1.2.13.8.59.23SECTION 413.230
     413.230 Determining the per treatment payment amount.
42:2.0.1.2.13.8.59.24SECTION 413.231
     413.231 Adjustment for wages.
42:2.0.1.2.13.8.59.25SECTION 413.232
     413.232 Low-volume adjustment.
42:2.0.1.2.13.8.59.26SECTION 413.233
     413.233 Rural facility adjustment.
42:2.0.1.2.13.8.59.27SECTION 413.234.
     413.234. Drug designation process.
42:2.0.1.2.13.8.59.28SECTION 413.235
     413.235 Patient-level adjustments.
42:2.0.1.2.13.8.59.29SECTION 413.236
     413.236 Transitional add-on payment adjustment for new and innovative equipment and supplies.
42:2.0.1.2.13.8.59.30SECTION 413.237
     413.237 Outliers.
42:2.0.1.2.13.8.59.31SECTION 413.239
     413.239 Transition period.
42:2.0.1.2.13.8.59.32SECTION 413.241
     413.241 Pharmacy arrangements.
42:2.0.1.2.13.9SUBPART I
Subpart I - Prospectively Determined Payment Rates for Low-Volume Skilled Nursing Facilities, for Cost Reporting Periods Beginning Prior to July 1, 1998
42:2.0.1.2.13.9.59.1SECTION 413.300
     413.300 Basis and scope.
42:2.0.1.2.13.9.59.2SECTION 413.302
     413.302 Definitions.
42:2.0.1.2.13.9.59.3SECTION 413.304
     413.304 Eligibility for prospectively determined payment rates.
42:2.0.1.2.13.9.59.4SECTION 413.308
     413.308 Rules governing election of prospectively determined payment rates.
42:2.0.1.2.13.9.59.5SECTION 413.310
     413.310 Basis of payment.
42:2.0.1.2.13.9.59.6SECTION 413.312
     413.312 Methodology for calculating rates.
42:2.0.1.2.13.9.59.7SECTION 413.314
     413.314 Determining payment amounts: Routine per diem rate.
42:2.0.1.2.13.9.59.8SECTION 413.316
     413.316 Determining payment amounts: Ancillary services.
42:2.0.1.2.13.9.59.9SECTION 413.320
     413.320 Publication of prospectively determined payment rates or amounts.
42:2.0.1.2.13.9.59.10SECTION 413.321
     413.321 Simplified cost report for SNFs.
42:2.0.1.2.13.10SUBPART J
Subpart J - Prospective Payment for Skilled Nursing Facilities
42:2.0.1.2.13.10.59.1SECTION 413.330
     413.330 Basis and scope.
42:2.0.1.2.13.10.59.2SECTION 413.333
     413.333 Definitions.
42:2.0.1.2.13.10.59.3SECTION 413.335
     413.335 Basis of payment.
42:2.0.1.2.13.10.59.4SECTION 413.337
     413.337 Methodology for calculating the prospective payment rates.
42:2.0.1.2.13.10.59.5SECTION 413.338
     413.338 Skilled nursing facility value-based purchasing program.
42:2.0.1.2.13.10.59.6SECTION 413.340
     413.340 Transition period.
42:2.0.1.2.13.10.59.7SECTION 413.343
     413.343 Resident assessment data.
42:2.0.1.2.13.10.59.8SECTION 413.345
     413.345 Publication of Federal prospective payment rates.
42:2.0.1.2.13.10.59.9SECTION 413.348
     413.348 Limitation on review.
42:2.0.1.2.13.10.59.10SECTION 413.350
     413.350 Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A services.
42:2.0.1.2.13.10.59.11SECTION 413.355
     413.355 Additional payment: QIO photocopy and mailing costs.
42:2.0.1.2.13.10.59.12SECTION 413.360
     413.360 Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
42:2.0.1.2.13.11SUBPART K
Subpart K - Payment for Acute Kidney Injury (AKI) Dialysis
42:2.0.1.2.13.11.59.1SECTION 413.370
     413.370 Scope.
42:2.0.1.2.13.11.59.2SECTION 413.371
     413.371 Definition.
42:2.0.1.2.13.11.59.3SECTION 413.372
     413.372 AKI dialysis payment rate.
42:2.0.1.2.13.11.59.4SECTION 413.373
     413.373 Other adjustments to the AKI dialysis payment rate
42:2.0.1.2.13.11.59.5SECTION 413.374
     413.374 Renal dialysis services included in the AKI dialysis payment rate
42:2.0.1.2.13.11.59.6SECTION 413.375
     413.375 Notification of changes in rate-setting methodologies and payment rates.