Title 42

CHAPTER IV SUBCHAP B

Subchapter B - Medicare Program

42:2.0.1.2.6	PART 405	PART 405 - FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
42:2.0.1.2.6.1	SUBPART A	Subpart A [Reserved]
42:2.0.1.2.6.2	SUBPART B	Subpart B - Medical Services Coverage Decisions That Relate to Health Care Technology
42:2.0.1.2.6.2.21.1	SECTION 405.201	405.201 Scope of subpart and definitions.
42:2.0.1.2.6.2.21.2	SECTION 405.203	405.203 FDA categorization of investigational devices.
42:2.0.1.2.6.2.21.3	SECTION 405.205	405.205 Coverage of a Category B (Nonexperimental/investigational) device.
42:2.0.1.2.6.2.21.4	SECTION 405.207	405.207 Services related to a noncovered device.
42:2.0.1.2.6.2.21.5	SECTION 405.209	405.209 Payment for a Category B (Nonexperimental/investigational) device.
42:2.0.1.2.6.2.21.6	SECTION 405.211	405.211 Coverage of items and services in FDA-approved IDE studies.
42:2.0.1.2.6.2.21.7	SECTION 405.212	405.212 Medicare Coverage IDE study criteria.
42:2.0.1.2.6.2.21.8	SECTION 405.213	405.213 Re-evaluation of a device categorization.
42:2.0.1.2.6.2.21.9	SECTION 405.215	405.215 Confidential commercial and trade secret information.
42:2.0.1.2.6.3	SUBPART C	Subpart C - Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans
42:2.0.1.2.6.3.21	SUBJGRP 21	General Provisions
42:2.0.1.2.6.3.21.1	SECTION 405.301	405.301 Scope of subpart.
42:2.0.1.2.6.3.22	SUBJGRP 22	Liability for Payments To Providers or Suppliers and Handling of Incorrect Payments
42:2.0.1.2.6.3.22.2	SECTION 405.350	405.350 Individual's liability for payments made to providers and other persons for items and services furnished the individual.
42:2.0.1.2.6.3.22.3	SECTION 405.351	405.351 Incorrect payments for which the individual is not liable.
42:2.0.1.2.6.3.22.4	SECTION 405.352	405.352 Adjustment of title XVIII incorrect payments.
42:2.0.1.2.6.3.22.5	SECTION 405.353	405.353 Certification of amount that will be adjusted against individual title II or railroad retirement benefits.
42:2.0.1.2.6.3.22.6	SECTION 405.354	405.354 Procedures for adjustment or recovery - title II beneficiary.
42:2.0.1.2.6.3.22.7	SECTION 405.355	405.355 Waiver of adjustment or recovery.
42:2.0.1.2.6.3.22.8	SECTION 405.356	405.356 Principles applied in waiver of adjustment or recovery.
42:2.0.1.2.6.3.22.9	SECTION 405.357	405.357 Notice of right to waiver consideration.
42:2.0.1.2.6.3.22.10	SECTION 405.358	405.358 When waiver of adjustment or recovery may be applied.
42:2.0.1.2.6.3.22.11	SECTION 405.359	405.359 Liability of certifying or disbursing officer.
42:2.0.1.2.6.3.23	SUBJGRP 23	Suspension and Recoupment of Payment to Providers and Suppliers and Collection and Compromise of Overpayments
42:2.0.1.2.6.3.23.12	SECTION 405.370	405.370 Definitions.
42:2.0.1.2.6.3.23.13	SECTION 405.371	405.371 Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
42:2.0.1.2.6.3.23.14	SECTION 405.372	405.372 Proceeding for suspension of payment.
42:2.0.1.2.6.3.23.15	SECTION 405.373	405.373 Proceeding for offset or recoupment.
42:2.0.1.2.6.3.23.16	SECTION 405.374	405.374 Opportunity for rebuttal.
42:2.0.1.2.6.3.23.17	SECTION 405.375	405.375 Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
42:2.0.1.2.6.3.23.18	SECTION 405.376	405.376 Suspension and termination of collection action and compromise of claims for overpayment.
42:2.0.1.2.6.3.23.19	SECTION 405.377	405.377 Withholding Medicare payments to recover Medicaid overpayments.
42:2.0.1.2.6.3.23.20	SECTION 405.378	405.378 Interest charges on overpayment and underpayments to providers, suppliers, and other entities.
42:2.0.1.2.6.3.23.21	SECTION 405.379	405.379 Limitation on recoupment of provider and supplier overpayments.
42:2.0.1.2.6.3.24	SUBJGRP 24	Repayment of Scholarships and Loans
42:2.0.1.2.6.3.24.22	SECTION 405.380	405.380 Collection of past-due amounts on scholarship and loan programs.
42:2.0.1.2.6.4	SUBPART D	Subpart D - Private Contracts
42:2.0.1.2.6.4.25.1	SECTION 405.400	405.400 Definitions.
42:2.0.1.2.6.4.25.2	SECTION 405.405	405.405 General rules.
42:2.0.1.2.6.4.25.3	SECTION 405.410	405.410 Conditions for properly opting-out of Medicare.
42:2.0.1.2.6.4.25.4	SECTION 405.415	405.415 Requirements of the private contract.
42:2.0.1.2.6.4.25.5	SECTION 405.420	405.420 Requirements of the opt-out affidavit.
42:2.0.1.2.6.4.25.6	SECTION 405.425	405.425 Effects of opting-out of Medicare.
42:2.0.1.2.6.4.25.7	SECTION 405.430	405.430 Failure to properly opt-out.
42:2.0.1.2.6.4.25.8	SECTION 405.435	405.435 Failure to maintain opt-out.
42:2.0.1.2.6.4.25.9	SECTION 405.440	405.440 Emergency and urgent care services.
42:2.0.1.2.6.4.25.10	SECTION 405.445	405.445 Cancellation of opt-out and early termination of opt-out.
42:2.0.1.2.6.4.25.11	SECTION 405.450	405.450 Appeals.
42:2.0.1.2.6.4.25.12	SECTION 405.455	405.455 Application to Medicare Advantage contracts.
42:2.0.1.2.6.5	SUBPART E	Subpart E - Criteria for Determining Reasonable Charges
42:2.0.1.2.6.5.25.1	SECTION 405.500	405.500 Basis.
42:2.0.1.2.6.5.25.2	SECTION 405.501	405.501 Determination of reasonable charges.
42:2.0.1.2.6.5.25.3	SECTION 405.502	405.502 Criteria for determining reasonable charges.
42:2.0.1.2.6.5.25.4	SECTION 405.503	405.503 Determining customary charges.
42:2.0.1.2.6.5.25.5	SECTION 405.504	405.504 Determining prevailing charges.
42:2.0.1.2.6.5.25.6	SECTION 405.505	405.505 Determination of locality.
42:2.0.1.2.6.5.25.7	SECTION 405.506	405.506 Charges higher than customary or prevailing charges or lowest charge levels.
42:2.0.1.2.6.5.25.8	SECTION 405.507	405.507 Illustrations of the application of the criteria for determining reasonable charges.
42:2.0.1.2.6.5.25.9	SECTION 405.508	405.508 Determination of comparable circumstances; limitation.
42:2.0.1.2.6.5.25.10	SECTION 405.509	405.509 Determining the inflation-indexed charge.
42:2.0.1.2.6.5.25.11	SECTION 405.511	405.511 Reasonable charges for medical services, supplies, and equipment.
42:2.0.1.2.6.5.25.12	SECTION 405.512	405.512 Carriers' procedural terminology and coding systems.
42:2.0.1.2.6.5.25.13	SECTION 405.515	405.515 Reimbursement for clinical laboratory services billed by physicians.
42:2.0.1.2.6.5.25.14	SECTION 405.517	405.517 Payment for drugs and biologicals that are not paid on a cost or prospective payment basis.
42:2.0.1.2.6.5.25.15	SECTION 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.
42:2.0.1.2.6.5.25.16	SECTION 405.534	405.534 Limitation on payment for screening mammography services.
42:2.0.1.2.6.5.25.17	SECTION 405.535	405.535 Special rule for nonparticipating physicians and suppliers furnishing screening mammography services before January 1, 2002.
42:2.0.1.2.6.6	SUBPART F	Subpart F - XXX
42:2.0.1.2.6.7	SUBPART G	Subpart G [Reserved]
42:2.0.1.2.6.8	SUBPART H	Subpart H - Appeals Under the Medicare Part B Program
42:2.0.1.2.6.8.25.1	SECTION 405.800	405.800 Appeals of CMS or a CMS contractor.
42:2.0.1.2.6.8.25.2	SECTION 405.803	405.803 Appeals rights.
42:2.0.1.2.6.8.25.3	SECTION 405.806	405.806 Impact of reversal of contractor determinations on claims processing.
42:2.0.1.2.6.8.25.4	SECTION 405.809	405.809 Reinstatement of provider or supplier billing privileges following corrective action.
42:2.0.1.2.6.8.25.5	SECTION 405.812	405.812 Effective date for DMEPOS supplier's billing privileges.
42:2.0.1.2.6.8.25.6	SECTION 405.815	405.815 Submission of claims.
42:2.0.1.2.6.8.25.7	SECTION 405.818	405.818 Deadline for processing provider enrollment initial determinations.
42:2.0.1.2.6.9	SUBPART I	Subpart I - Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)
42:2.0.1.2.6.9.25	SUBJGRP 25	Initial Determinations
42:2.0.1.2.6.9.25.1	SECTION 405.900	405.900 Basis and scope.
42:2.0.1.2.6.9.25.2	SECTION 405.902	405.902 Definitions.
42:2.0.1.2.6.9.25.3	SECTION 405.904	405.904 Medicare initial determinations, redeterminations and appeals: General description.
42:2.0.1.2.6.9.25.4	SECTION 405.906	405.906 Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.
42:2.0.1.2.6.9.25.5	SECTION 405.908	405.908 Medicaid State agencies.
42:2.0.1.2.6.9.25.6	SECTION 405.910	405.910 Appointed representatives.
42:2.0.1.2.6.9.25.7	SECTION 405.912	405.912 Assignment of appeal rights.
42:2.0.1.2.6.9.25.8	SECTION 405.920	405.920 Initial determinations.
42:2.0.1.2.6.9.25.9	SECTION 405.921	405.921 Notice of initial determination.
42:2.0.1.2.6.9.25.10	SECTION 405.922	405.922 Time frame for processing initial determinations.
42:2.0.1.2.6.9.25.11	SECTION 405.924	405.924 Actions that are initial determinations.
42:2.0.1.2.6.9.25.12	SECTION 405.925	405.925 Decisions of utilization review committees.
42:2.0.1.2.6.9.25.13	SECTION 405.926	405.926 Actions that are not initial determinations.
42:2.0.1.2.6.9.25.14	SECTION 405.927	405.927 Initial determinations subject to the reopenings process.
42:2.0.1.2.6.9.25.15	SECTION 405.928	405.928 Effect of the initial determination.
42:2.0.1.2.6.9.26	SUBJGRP 26	Redeterminations
42:2.0.1.2.6.9.26.16	SECTION 405.940	405.940 Right to a redetermination.
42:2.0.1.2.6.9.26.17	SECTION 405.942	405.942 Time frame for filing a request for a redetermination.
42:2.0.1.2.6.9.26.18	SECTION 405.944	405.944 Place and method of filing a request for a redetermination.
42:2.0.1.2.6.9.26.19	SECTION 405.946	405.946 Evidence to be submitted with the redetermination request.
42:2.0.1.2.6.9.26.20	SECTION 405.947	405.947 Notice to the beneficiary of applicable plan's request for a redetermination.
42:2.0.1.2.6.9.26.21	SECTION 405.948	405.948 Conduct of a redetermination.
42:2.0.1.2.6.9.26.22	SECTION 405.950	405.950 Time frame for making a redetermination.
42:2.0.1.2.6.9.26.23	SECTION 405.952	405.952 Withdrawal or dismissal of a request for a redetermination.
42:2.0.1.2.6.9.26.24	SECTION 405.954	405.954 Redetermination.
42:2.0.1.2.6.9.26.25	SECTION 405.956	405.956 Notice of a redetermination.
42:2.0.1.2.6.9.26.26	SECTION 405.958	405.958 Effect of a redetermination.
42:2.0.1.2.6.9.27	SUBJGRP 27	Reconsideration
42:2.0.1.2.6.9.27.27	SECTION 405.960	405.960 Right to a reconsideration.
42:2.0.1.2.6.9.27.28	SECTION 405.962	405.962 Timeframe for filing a request for a reconsideration.
42:2.0.1.2.6.9.27.29	SECTION 405.964	405.964 Place and method of filing a request for a reconsideration.
42:2.0.1.2.6.9.27.30	SECTION 405.966	405.966 Evidence to be submitted with the reconsideration request.
42:2.0.1.2.6.9.27.31	SECTION 405.968	405.968 Conduct of a reconsideration.
42:2.0.1.2.6.9.27.32	SECTION 405.970	405.970 Timeframe for making a reconsideration following a contractor redetermination.
42:2.0.1.2.6.9.27.33	SECTION 405.972	405.972 Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.
42:2.0.1.2.6.9.27.34	SECTION 405.974	405.974 Reconsideration and review of a contractor's dismissal of a request for redetermination.
42:2.0.1.2.6.9.27.35	SECTION 405.976	405.976 Notice of a reconsideration.
42:2.0.1.2.6.9.27.36	SECTION 405.978	405.978 Effect of a reconsideration.
42:2.0.1.2.6.9.28	SUBJGRP 28	Reopenings
42:2.0.1.2.6.9.28.37	SECTION 405.980	405.980 Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.
42:2.0.1.2.6.9.28.38	SECTION 405.982	405.982 Notice of a revised determination or decision.
42:2.0.1.2.6.9.28.39	SECTION 405.984	405.984 Effect of a revised determination or decision.
42:2.0.1.2.6.9.28.40	SECTION 405.986	405.986 Good cause for reopening.
42:2.0.1.2.6.9.29	SUBJGRP 29	Expedited Access to Judicial Review
42:2.0.1.2.6.9.29.41	SECTION 405.990	405.990 Expedited access to judicial review.
42:2.0.1.2.6.9.30	SUBJGRP 30	ALJ Hearings
42:2.0.1.2.6.9.30.42	SECTION 405.1000	405.1000 Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
42:2.0.1.2.6.9.30.43	SECTION 405.1002	405.1002 Right to an ALJ hearing.
42:2.0.1.2.6.9.30.44	SECTION 405.1004	405.1004 Right to a review of QIC notice of dismissal.
42:2.0.1.2.6.9.30.45	SECTION 405.1006	405.1006 Amount in controversy required for an ALJ hearing and judicial review.
42:2.0.1.2.6.9.30.46	SECTION 405.1008	405.1008 Parties to the proceedings on a request for an ALJ hearing.
42:2.0.1.2.6.9.30.47	SECTION 405.1010	405.1010 When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.
42:2.0.1.2.6.9.30.48	SECTION 405.1012	405.1012 When CMS or its contractors may be a party to a hearing.
42:2.0.1.2.6.9.30.49	SECTION 405.1014	405.1014 Request for an ALJ hearing or a review of a QIC dismissal.
42:2.0.1.2.6.9.30.50	SECTION 405.1016	405.1016 Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.
42:2.0.1.2.6.9.30.51	SECTION 405.1018	405.1018 Submitting evidence.
42:2.0.1.2.6.9.30.52	SECTION 405.1020	405.1020 Time and place for a hearing before an ALJ.
42:2.0.1.2.6.9.30.53	SECTION 405.1022	405.1022 Notice of a hearing before an ALJ.
42:2.0.1.2.6.9.30.54	SECTION 405.1024	405.1024 Objections to the issues.
42:2.0.1.2.6.9.30.55	SECTION 405.1026	405.1026 Disqualification of the ALJ or attorney adjudicator.
42:2.0.1.2.6.9.30.56	SECTION 405.1028	405.1028 Review of evidence submitted by parties.
42:2.0.1.2.6.9.30.57	SECTION 405.1030	405.1030 ALJ hearing procedures.
42:2.0.1.2.6.9.30.58	SECTION 405.1032	405.1032 Issues before an ALJ or attorney adjudicator.
42:2.0.1.2.6.9.30.59	SECTION 405.1034	405.1034 Requesting information from the QIC.
42:2.0.1.2.6.9.30.60	SECTION 405.1036	405.1036 Description of an ALJ hearing process.
42:2.0.1.2.6.9.30.61	SECTION 405.1037	405.1037 Discovery.
42:2.0.1.2.6.9.30.62	SECTION 405.1038	405.1038 Deciding a case without a hearing before an ALJ.
42:2.0.1.2.6.9.30.63	SECTION 405.1040	405.1040 Prehearing and posthearing conferences.
42:2.0.1.2.6.9.30.64	SECTION 405.1042	405.1042 The administrative record.
42:2.0.1.2.6.9.30.65	SECTION 405.1044	405.1044 Consolidated proceedings.
42:2.0.1.2.6.9.30.66	SECTION 405.1046	405.1046 Notice of an ALJ or attorney adjudicator decision.
42:2.0.1.2.6.9.30.67	SECTION 405.1048	405.1048 The effect of an ALJ's or attorney adjudicator's decision.
42:2.0.1.2.6.9.30.68	SECTION 405.1050	405.1050 Removal of a hearing request from OMHA to the Council.
42:2.0.1.2.6.9.30.69	SECTION 405.1052	405.1052 Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.
42:2.0.1.2.6.9.30.70	SECTION 405.1054	405.1054 Effect of dismissal of a request for a hearing or request for review of QIC dismissal.
42:2.0.1.2.6.9.30.71	SECTION 405.1056	405.1056 Remands of requests for hearing and requests for review.
42:2.0.1.2.6.9.30.72	SECTION 405.1058	405.1058 Effect of a remand.
42:2.0.1.2.6.9.31	SUBJGRP 31	Applicability of Medicare Coverage Policies
42:2.0.1.2.6.9.31.73	SECTION 405.1060	405.1060 Applicability of national coverage determinations (NCDs).
42:2.0.1.2.6.9.31.74	SECTION 405.1062	405.1062 Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.
42:2.0.1.2.6.9.31.75	SECTION 405.1063	405.1063 Applicability of laws, regulations, CMS Rulings, and precedential decisions.
42:2.0.1.2.6.9.32	SUBJGRP 32	Medicare Appeals Council Review
42:2.0.1.2.6.9.32.76	SECTION 405.1100	405.1100 Medicare Appeals Council review: General.
42:2.0.1.2.6.9.32.77	SECTION 405.1102	405.1102 Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
42:2.0.1.2.6.9.32.78	SECTION 405.1106	405.1106 Where a request for review or escalation may be filed.
42:2.0.1.2.6.9.32.79	SECTION 405.1108	405.1108 Council actions when request for review or escalation is filed.
42:2.0.1.2.6.9.32.80	SECTION 405.1110	405.1110 Council reviews on its own motion.
42:2.0.1.2.6.9.32.81	SECTION 405.1112	405.1112 Content of request for review.
42:2.0.1.2.6.9.32.82	SECTION 405.1114	405.1114 Dismissal of request for review.
42:2.0.1.2.6.9.32.83	SECTION 405.1116	405.1116 Effect of dismissal of request for Council review or request for hearing.
42:2.0.1.2.6.9.32.84	SECTION 405.1118	405.1118 Obtaining evidence from the Council.
42:2.0.1.2.6.9.32.85	SECTION 405.1120	405.1120 Filing briefs with the Council.
42:2.0.1.2.6.9.32.86	SECTION 405.1122	405.1122 What evidence may be submitted to the Council.
42:2.0.1.2.6.9.32.87	SECTION 405.1124	405.1124 Oral argument.
42:2.0.1.2.6.9.32.88	SECTION 405.1126	405.1126 Case remanded by the Council.
42:2.0.1.2.6.9.32.89	SECTION 405.1128	405.1128 Action of the Council.
42:2.0.1.2.6.9.32.90	SECTION 405.1130	405.1130 Effect of the Council's decision.
42:2.0.1.2.6.9.32.91	SECTION 405.1132	405.1132 Request for escalation to Federal court.
42:2.0.1.2.6.9.32.92	SECTION 405.1134	405.1134 Extension of time to file action in Federal district court.
42:2.0.1.2.6.9.32.93	SECTION 405.1136	405.1136 Judicial review.
42:2.0.1.2.6.9.32.94	SECTION 405.1138	405.1138 Case remanded by a Federal district court.
42:2.0.1.2.6.9.32.95	SECTION 405.1140	405.1140 Council review of ALJ decision in a case remanded by a Federal district court.
42:2.0.1.2.6.10	SUBPART J	Subpart J - Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges
42:2.0.1.2.6.10.33.1	SECTION 405.1200	405.1200 Notifying beneficiaries of provider service terminations.
42:2.0.1.2.6.10.33.2	SECTION 405.1202	405.1202 Expedited determination procedures.
42:2.0.1.2.6.10.33.3	SECTION 405.1204	405.1204 Expedited reconsiderations.
42:2.0.1.2.6.10.33.4	SECTION 405.1205	405.1205 Notifying beneficiaries of hospital discharge appeal rights.
42:2.0.1.2.6.10.33.5	SECTION 405.1206	405.1206 Expedited determination procedures for inpatient hospital care.
42:2.0.1.2.6.10.33.6	SECTION 405.1208	405.1208 Hospital requests expedited QIO review.
42:2.0.1.2.6.11	SUBPART K	Subparts K-Q [Reserved]
42:2.0.1.2.6.12	SUBPART R	Subpart R - Provider Reimbursement Determinations and Appeals
42:2.0.1.2.6.12.33.1	SECTION 405.1801	405.1801 Introduction.
42:2.0.1.2.6.12.33.2	SECTION 405.1803	405.1803 Contractor determination and notice of amount of program reimbursement.
42:2.0.1.2.6.12.33.3	SECTION 405.1804	405.1804 Matters not subject to administrative and judicial review under prospective payment.
42:2.0.1.2.6.12.33.4	SECTION 405.1805	405.1805 Parties to contractor determination.
42:2.0.1.2.6.12.33.5	SECTION 405.1807	405.1807 Effect of contractor determination.
42:2.0.1.2.6.12.33.6	SECTION 405.1809	405.1809 Contractor hearing procedures.
42:2.0.1.2.6.12.33.7	SECTION 405.1811	405.1811 Right to contractor hearing; contents of, and adding issues to, hearing request.
42:2.0.1.2.6.12.33.8	SECTION 405.1813	405.1813 Good cause extension of time limit for requesting a contractor hearing.
42:2.0.1.2.6.12.33.9	SECTION 405.1814	405.1814 Contractor hearing officer jurisdiction.
42:2.0.1.2.6.12.33.10	SECTION 405.1815	405.1815 Parties to proceedings before the contractor hearing officer(s).
42:2.0.1.2.6.12.33.11	SECTION 405.1817	405.1817 Hearing officer or panel of hearing officers authorized to conduct contractor hearing; disqualification of officers.
42:2.0.1.2.6.12.33.12	SECTION 405.1819	405.1819 Conduct of contractor hearing.
42:2.0.1.2.6.12.33.13	SECTION 405.1821	405.1821 Prehearing discovery and other proceedings prior to the contractor hearing.
42:2.0.1.2.6.12.33.14	SECTION 405.1823	405.1823 Evidence at contractor hearing.
42:2.0.1.2.6.12.33.15	SECTION 405.1825	405.1825 Witnesses at contractor hearing.
42:2.0.1.2.6.12.33.16	SECTION 405.1827	405.1827 Record of proceedings before the contractor hearing officer(s).
42:2.0.1.2.6.12.33.17	SECTION 405.1829	405.1829 Scope of authority of contractor hearing officer(s).
42:2.0.1.2.6.12.33.18	SECTION 405.1831	405.1831 Contractor hearing decision.
42:2.0.1.2.6.12.33.19	SECTION 405.1832	405.1832 Contractor hearing officer review of compliance with the substantive reimbursement requirement of an appropriate cost report claim.
42:2.0.1.2.6.12.33.20	SECTION 405.1833	405.1833 Effect of contractor hearing decision.
42:2.0.1.2.6.12.33.21	SECTION 405.1834	405.1834 CMS reviewing official procedure.
42:2.0.1.2.6.12.33.22	SECTION 405.1835	405.1835 Right to Board hearing; contents of, and adding issues to, hearing request.
42:2.0.1.2.6.12.33.23	SECTION 405.1836	405.1836 Good cause extension of time limit for requesting a Board hearing.
42:2.0.1.2.6.12.33.24	SECTION 405.1837	405.1837 Group appeals.
42:2.0.1.2.6.12.33.25	SECTION 405.1839	405.1839 Amount in controversy.
42:2.0.1.2.6.12.33.26	SECTION 405.1840	405.1840 Board jurisdiction.
42:2.0.1.2.6.12.33.27	SECTION 405.1842	405.1842 Expedited judicial review.
42:2.0.1.2.6.12.33.28	SECTION 405.1843	405.1843 Parties to proceedings in a Board appeal.
42:2.0.1.2.6.12.33.29	SECTION 405.1845	405.1845 Composition of Board; hearings, decisions, and remands.
42:2.0.1.2.6.12.33.30	SECTION 405.1847	405.1847 Disqualification of Board members.
42:2.0.1.2.6.12.33.31	SECTION 405.1849	405.1849 Establishment of time and place of hearing by the Board.
42:2.0.1.2.6.12.33.32	SECTION 405.1851	405.1851 Conduct of Board hearing.
42:2.0.1.2.6.12.33.33	SECTION 405.1853	405.1853 Board proceedings prior to any hearing; discovery.
42:2.0.1.2.6.12.33.34	SECTION 405.1855	405.1855 Evidence at Board hearing.
42:2.0.1.2.6.12.33.35	SECTION 405.1857	405.1857 Subpoenas.
42:2.0.1.2.6.12.33.36	SECTION 405.1859	405.1859 Witnesses.
42:2.0.1.2.6.12.33.37	SECTION 405.1861	405.1861 Oral argument and written allegations.
42:2.0.1.2.6.12.33.38	SECTION 405.1863	405.1863 Administrative policy at issue.
42:2.0.1.2.6.12.33.39	SECTION 405.1865	405.1865 Record of administrative proceedings.
42:2.0.1.2.6.12.33.40	SECTION 405.1867	405.1867 Scope of Board's legal authority.
42:2.0.1.2.6.12.33.41	SECTION 405.1868	405.1868 Board actions in response to failure to follow Board rules.
42:2.0.1.2.6.12.33.42	SECTION 405.1869	405.1869 Scope of Board's authority in a hearing decision.
42:2.0.1.2.6.12.33.43	SECTION 405.1871	405.1871 Board hearing decision.
42:2.0.1.2.6.12.33.44	SECTION 405.1873	405.1873 Board review of compliance with the reimbursement requirement of an appropriate cost report claim.
42:2.0.1.2.6.12.33.45	SECTION 405.1875	405.1875 Administrator review.
42:2.0.1.2.6.12.33.46	SECTION 405.1877	405.1877 Judicial review.
42:2.0.1.2.6.12.33.47	SECTION 405.1881	405.1881 Appointment of representative.
42:2.0.1.2.6.12.33.48	SECTION 405.1883	405.1883 Authority of representative.
42:2.0.1.2.6.12.33.49	SECTION 405.1885	405.1885 Reopening a contractor determination or reviewing entity decision.
42:2.0.1.2.6.12.33.50	SECTION 405.1887	405.1887 Notice of reopening; effect of reopening.
42:2.0.1.2.6.12.33.51	SECTION 405.1889	405.1889 Effect of a revision; issue-specific nature of appeals of revised determinations and decisions.
42:2.0.1.2.6.13	SUBPART S	Subparts S-T [Reserved]
42:2.0.1.2.6.14	SUBPART U	Subpart U - Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services
42:2.0.1.2.6.14.33.1	SECTION 405.2100-405.2101	405.2100-405.2101 [Reserved]
42:2.0.1.2.6.14.33.2	SECTION 405.2102	405.2102 Definitions.
42:2.0.1.2.6.14.33.3	SECTION 405.2110	405.2110 Designation of ESRD networks.
42:2.0.1.2.6.14.33.4	SECTION 405.2111	405.2111 [Reserved]
42:2.0.1.2.6.14.33.5	SECTION 405.2112	405.2112 ESRD network organizations.
42:2.0.1.2.6.14.33.6	SECTION 405.2113	405.2113 Medical review board.
42:2.0.1.2.6.14.33.7	SECTION 405.2114	405.2114 [Reserved]
42:2.0.1.2.6.14.33.8	SECTION 405.2131-405.2184	405.2131-405.2184 [Reserved]
42:2.0.1.2.6.15	SUBPART V	Subparts V-W [Reserved]
42:2.0.1.2.6.16	SUBPART X	Subpart X - Rural Health Clinic and Federally Qualified Health Center Services
42:2.0.1.2.6.16.33	SUBJGRP 33	Federally Qualified Health Center Services
42:2.0.1.2.6.16.33.1	SECTION 405.2400	405.2400 Basis.
42:2.0.1.2.6.16.33.2	SECTION 405.2401	405.2401 Scope and definitions.
42:2.0.1.2.6.16.33.3	SECTION 405.2402	405.2402 Rural health clinic basic requirements.
42:2.0.1.2.6.16.33.4	SECTION 405.2403	405.2403 Rural health clinic content and terms of the agreement with the Secretary.
42:2.0.1.2.6.16.33.5	SECTION 405.2404	405.2404 Termination of rural health clinic agreements.
42:2.0.1.2.6.16.33.6	SECTION 405.2410	405.2410 Application of Part B deductible and coinsurance.
42:2.0.1.2.6.16.33.7	SECTION 405.2411	405.2411 Scope of benefits.
42:2.0.1.2.6.16.33.8	SECTION 405.2412	405.2412 Physicians' services.
42:2.0.1.2.6.16.33.9	SECTION 405.2413	405.2413 Services and supplies incident to a physician's services.
42:2.0.1.2.6.16.33.10	SECTION 405.2414	405.2414 Nurse practitioner, physician assistant, and certified nurse midwife services.
42:2.0.1.2.6.16.33.11	SECTION 405.2415	405.2415 Incident to services and direct supervision.
42:2.0.1.2.6.16.33.12	SECTION 405.2416	405.2416 Visiting nurse services.
42:2.0.1.2.6.16.33.13	SECTION 405.2417	405.2417 Visiting nurse services: Determination of shortage of agencies.
42:2.0.1.2.6.16.33.14	SECTION 405.2430	405.2430 Basic requirements.
42:2.0.1.2.6.16.33.15	SECTION 405.2434	405.2434 Content and terms of the agreement.
42:2.0.1.2.6.16.33.16	SECTION 405.2436	405.2436 Termination of agreement.
42:2.0.1.2.6.16.33.17	SECTION 405.2440	405.2440 Conditions for reinstatement after termination by CMS.
42:2.0.1.2.6.16.33.18	SECTION 405.2442	405.2442 Notice to the public.
42:2.0.1.2.6.16.33.19	SECTION 405.2444	405.2444 Change of ownership.
42:2.0.1.2.6.16.33.20	SECTION 405.2446	405.2446 Scope of services.
42:2.0.1.2.6.16.33.21	SECTION 405.2448	405.2448 Preventive primary services.
42:2.0.1.2.6.16.33.22	SECTION 405.2449	405.2449 Preventive services.
42:2.0.1.2.6.16.33.23	SECTION 405.2450	405.2450 Clinical psychologist and clinical social worker services.
42:2.0.1.2.6.16.33.24	SECTION 405.2452	405.2452 Services and supplies incident to clinical psychologist and clinical social worker services.
42:2.0.1.2.6.16.34	SUBJGRP 34	Payment for Rural Health Clinic and Federally Qualified Health Center Services
42:2.0.1.2.6.16.34.25	SECTION 405.2460	405.2460 Applicability of general payment exclusions.
42:2.0.1.2.6.16.34.26	SECTION 405.2462	405.2462 Payment for RHC and FQHC services.
42:2.0.1.2.6.16.34.27	SECTION 405.2463	405.2463 What constitutes a visit.
42:2.0.1.2.6.16.34.28	SECTION 405.2464	405.2464 Payment rate.
42:2.0.1.2.6.16.34.29	SECTION 405.2466	405.2466 Annual reconciliation.
42:2.0.1.2.6.16.34.30	SECTION 405.2467	405.2467 Requirements of the FQHC PPS.
42:2.0.1.2.6.16.34.31	SECTION 405.2468	405.2468 Allowable costs.
42:2.0.1.2.6.16.34.32	SECTION 405.2469	405.2469 FQHC supplemental payments.
42:2.0.1.2.6.16.34.33	SECTION 405.2470	405.2470 Reports and maintenance of records.
42:2.0.1.2.6.16.34.34	SECTION 405.2472	405.2472 Beneficiary appeals.
42:2.0.1.2.7	PART 406	PART 406 - HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT
42:2.0.1.2.7.1	SUBPART A	Subpart A - General Provisions
42:2.0.1.2.7.1.35.1	SECTION 406.1	406.1 Statutory basis.
42:2.0.1.2.7.1.35.2	SECTION 406.2	406.2 Scope.
42:2.0.1.2.7.1.35.3	SECTION 406.3	406.3 Definitions.
42:2.0.1.2.7.1.35.4	SECTION 406.5	406.5 Basis of eligibility and entitlement.
42:2.0.1.2.7.1.35.5	SECTION 406.6	406.6 Application or enrollment for hospital insurance.
42:2.0.1.2.7.1.35.6	SECTION 406.7	406.7 Forms to apply for entitlement under Medicare Part A.
42:2.0.1.2.7.2	SUBPART B	Subpart B - Hospital Insurance Without Monthly Premiums
42:2.0.1.2.7.2.35.1	SECTION 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.
42:2.0.1.2.7.2.35.2	SECTION 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.
42:2.0.1.2.7.2.35.3	SECTION 406.12	406.12 Individual under age 65 who is entitled to social security or railroad retirement disability benefits.
42:2.0.1.2.7.2.35.4	SECTION 406.13	406.13 Individual who has end-stage renal disease.
42:2.0.1.2.7.2.35.5	SECTION 406.15	406.15 Special provisions applicable to Medicare qualified government employment.
42:2.0.1.2.7.3	SUBPART C	Subpart C - Premium Hospital Insurance
42:2.0.1.2.7.3.35.1	SECTION 406.20	406.20 Basic requirements.
42:2.0.1.2.7.3.35.2	SECTION 406.21	406.21 Individual enrollment.
42:2.0.1.2.7.3.35.3	SECTION 406.22	406.22 Effect of month of enrollment on entitlement.
42:2.0.1.2.7.3.35.4	SECTION 406.24	406.24 Special enrollment period related to coverage under group health plans.
42:2.0.1.2.7.3.35.5	SECTION 406.25	406.25 Special enrollment period for volunteers outside the United States.
42:2.0.1.2.7.3.35.6	SECTION 406.26	406.26 Enrollment under State buy-in.
42:2.0.1.2.7.3.35.7	SECTION 406.28	406.28 End of entitlement.
42:2.0.1.2.7.3.35.8	SECTION 406.32	406.32 Monthly premiums.
42:2.0.1.2.7.3.35.9	SECTION 406.33	406.33 Determination of months to be counted for premium increase: Enrollment.
42:2.0.1.2.7.3.35.10	SECTION 406.34	406.34 Determination of months to be counted for premium increase: Reenrollment.
42:2.0.1.2.7.3.35.11	SECTION 406.38	406.38 Prejudice to enrollment rights because of Federal Government error.
42:2.0.1.2.7.4	SUBPART D	Subpart D - Special Circumstances That Affect Entitlement to Hospital Insurance
42:2.0.1.2.7.4.35.1	SECTION 406.50	406.50 Nonpayment of benefits on behalf of certain aliens.
42:2.0.1.2.7.4.35.2	SECTION 406.52	406.52 Conviction of certain offenses.
42:2.0.1.2.8	PART 407	PART 407 - SUPPLEMENTARY MEDICAL INSURANCE (SMI) ENROLLMENT AND ENTITLEMENT
42:2.0.1.2.8.1	SUBPART A	Subpart A - General Provisions
42:2.0.1.2.8.1.35.1	SECTION 407.1	407.1 Basis and scope.
42:2.0.1.2.8.1.35.2	SECTION 407.2	407.2 General description of program.
42:2.0.1.2.8.1.35.3	SECTION 407.4	407.4 Basic requirements for entitlement.
42:2.0.1.2.8.2	SUBPART B	Subpart B - Individual Enrollment and Entitlement for SMI
42:2.0.1.2.8.2.35.1	SECTION 407.10	407.10 Eligibility to enroll.
42:2.0.1.2.8.2.35.2	SECTION 407.11	407.11 Forms used to apply for enrollment under Medicare Part B.
42:2.0.1.2.8.2.35.3	SECTION 407.12	407.12 General enrollment provisions.
42:2.0.1.2.8.2.35.4	SECTION 407.14	407.14 Initial enrollment period.
42:2.0.1.2.8.2.35.5	SECTION 407.15	407.15 General enrollment period.
42:2.0.1.2.8.2.35.6	SECTION 407.17	407.17 Automatic enrollment.
42:2.0.1.2.8.2.35.7	SECTION 407.18	407.18 Determining month of automatic enrollment.
42:2.0.1.2.8.2.35.8	SECTION 407.20	407.20 Special enrollment period related to coverage under group health plans.
42:2.0.1.2.8.2.35.9	SECTION 407.21	407.21 Special enrollment period for volunteers outside the United States.
42:2.0.1.2.8.2.35.10	SECTION 407.22	407.22 Request for individual enrollment.
42:2.0.1.2.8.2.35.11	SECTION 407.25	407.25 Beginning of entitlement: Individual enrollment.
42:2.0.1.2.8.2.35.12	SECTION 407.27	407.27 Termination of entitlement: Individual enrollment.
42:2.0.1.2.8.2.35.13	SECTION 407.30	407.30 Limitations on enrollment.
42:2.0.1.2.8.2.35.14	SECTION 407.32	407.32 Prejudice to enrollment rights because of Federal Government misrepresentation, inaction, or error.
42:2.0.1.2.8.3	SUBPART C	Subpart C - State Buy-In Agreements
42:2.0.1.2.8.3.35.1	SECTION 407.40	407.40 Enrollment under a State buy-in agreement.
42:2.0.1.2.8.3.35.2	SECTION 407.42	407.42 Buy-in groups available to the 50 States, the District of Columbia, and the Northern Mariana Islands.
42:2.0.1.2.8.3.35.3	SECTION 407.43	407.43 Buy-in groups available to Puerto Rico, Guam, the Virgin Islands, and American Samoa.
42:2.0.1.2.8.3.35.4	SECTION 407.45	407.45 Termination of State buy-in agreements.
42:2.0.1.2.8.3.35.5	SECTION 407.47	407.47 Beginning of coverage under a State buy-in agreement.
42:2.0.1.2.8.3.35.6	SECTION 407.48	407.48 Termination of coverage under a State buy-in agreement.
42:2.0.1.2.8.3.35.7	SECTION 407.50	407.50 Continuation of coverage: Individual enrollment following end of coverage under a State buy-in agreement.
42:2.0.1.2.9	PART 408	PART 408 - PREMIUMS FOR SUPPLEMENTARY MEDICAL INSURANCE
42:2.0.1.2.9.1	SUBPART A	Subpart A - General Provisions
42:2.0.1.2.9.1.35.1	SECTION 408.1	408.1 Statutory basis.
42:2.0.1.2.9.1.35.2	SECTION 408.2	408.2 Scope and purpose.
42:2.0.1.2.9.1.35.3	SECTION 408.3	408.3 Definitions.
42:2.0.1.2.9.1.35.4	SECTION 408.4	408.4 Payment obligations.
42:2.0.1.2.9.1.35.5	SECTION 408.6	408.6 Methods and priorities for payment.
42:2.0.1.2.9.1.35.6	SECTION 408.8	408.8 Grace period and termination date.
42:2.0.1.2.9.1.35.7	SECTION 408.10	408.10 Claim for monthly benefits pending concurrently with request for SMI enrollment.
42:2.0.1.2.9.2	SUBPART B	Subpart B - Amount of Monthly Premiums
42:2.0.1.2.9.2.35.1	SECTION 408.20	408.20 Monthly premiums.
42:2.0.1.2.9.2.35.2	SECTION 408.21	408.21 Reduction in Medicare Part B premium as an additional benefit under Medicare + Choice plans.
42:2.0.1.2.9.2.35.3	SECTION 408.22	408.22 Increased premiums for late enrollment and for reenrollment.
42:2.0.1.2.9.2.35.4	SECTION 408.24	408.24 Individuals who enrolled or reenrolled before April 1, 1981 or after September 30, 1981.
42:2.0.1.2.9.2.35.5	SECTION 408.25	408.25 Individuals who enrolled or reenrolled between April 1 and September 30, 1981.
42:2.0.1.2.9.2.35.6	SECTION 408.26	408.26 Examples.
42:2.0.1.2.9.2.35.7	SECTION 408.27	408.27 Rounding the monthly premium.
42:2.0.1.2.9.2.35.8	SECTION 408.28	408.28 Increased premiums due to the income-related monthly adjustment amount (IRMAA).
42:2.0.1.2.9.3	SUBPART C	Subpart C - Deduction From Monthly Benefits
42:2.0.1.2.9.3.35.1	SECTION 408.40	408.40 Deduction from monthly benefits: Basic rules.
42:2.0.1.2.9.3.35.2	SECTION 408.42	408.42 Deduction from railroad retirement benefits.
42:2.0.1.2.9.3.35.3	SECTION 408.43	408.43 Deduction from social security benefits.
42:2.0.1.2.9.3.35.4	SECTION 408.44	408.44 Deduction from civil service annuities.
42:2.0.1.2.9.3.35.5	SECTION 408.45	408.45 Deduction from age 72 special payments.
42:2.0.1.2.9.3.35.6	SECTION 408.46	408.46 Effect of suspension of social security benefits.
42:2.0.1.2.9.3.35.7	SECTION 408.47	408.47 [Reserved]
42:2.0.1.2.9.3.35.8	SECTION 408.50	408.50 When premiums are considered paid.
42:2.0.1.2.9.3.35.9	SECTION 408.52	408.52 Change from direct remittance to deduction.
42:2.0.1.2.9.3.35.10	SECTION 408.53	408.53 Change from partial direct remittance to full deduction.
42:2.0.1.2.9.4	SUBPART D	Subpart D - Direct Remittance: Individual Payment
42:2.0.1.2.9.4.35.1	SECTION 408.60	408.60 Direct remittance: Basic rules.
42:2.0.1.2.9.4.35.2	SECTION 408.62	408.62 Initial and subsequent billings.
42:2.0.1.2.9.4.35.3	SECTION 408.63	408.63 Billing procedures when monthly benefits are less than monthly premiums.
42:2.0.1.2.9.4.35.4	SECTION 408.65	408.65 Payment options.
42:2.0.1.2.9.4.35.5	SECTION 408.68	408.68 When premiums are considered paid.
42:2.0.1.2.9.4.35.6	SECTION 408.70	408.70 Change from quarterly to monthly payments.
42:2.0.1.2.9.4.35.7	SECTION 408.71	408.71 Change from deduction or State payment to direct remittance.
42:2.0.1.2.9.5	SUBPART E	Subpart E - Direct Remittance: Group Payment
42:2.0.1.2.9.5.35.1	SECTION 408.80	408.80 Basic rules.
42:2.0.1.2.9.5.35.2	SECTION 408.82	408.82 Conditions for group billing.
42:2.0.1.2.9.5.35.3	SECTION 408.84	408.84 Billing and payment procedures.
42:2.0.1.2.9.5.35.4	SECTION 408.86	408.86 Responsibilities under group billing arrangement.
42:2.0.1.2.9.5.35.5	SECTION 408.88	408.88 Refund of group payments.
42:2.0.1.2.9.5.35.6	SECTION 408.90	408.90 Termination of group billing arrangement.
42:2.0.1.2.9.5.35.7	SECTION 408.92	408.92 Change from group payment to deduction or individual payment.
42:2.0.1.2.9.6	SUBPART F	Subpart F - Termination and Reinstatement of Coverage
42:2.0.1.2.9.6.35.1	SECTION 408.100	408.100 Termination of coverage for nonpayment of premiums.
42:2.0.1.2.9.6.35.2	SECTION 408.102	408.102 Reconsideration of termination.
42:2.0.1.2.9.6.35.3	SECTION 408.104	408.104 Reinstatement procedures.
42:2.0.1.2.9.7	SUBPART G	Subpart G - Collection of Unpaid Premiums; Refund of Excess Premiums After the Death of the Enrollee
42:2.0.1.2.9.7.35.1	SECTION 408.110	408.110 Collection of unpaid premiums.
42:2.0.1.2.9.7.35.2	SECTION 408.112	408.112 Refund of excess premiums after the enrollee dies.
42:2.0.1.2.9.8	SUBPART H	Subpart H - Supplementary Medical Insurance Premium Surcharge Agreements
42:2.0.1.2.9.8.35.1	SECTION 408.200	408.200 Statutory basis.
42:2.0.1.2.9.8.35.2	SECTION 408.201	408.201 Definitions.
42:2.0.1.2.9.8.35.3	SECTION 408.202	408.202 Conditions for participation.
42:2.0.1.2.9.8.35.4	SECTION 408.205	408.205 Application procedures.
42:2.0.1.2.9.8.35.5	SECTION 408.207	408.207 Billing and payment procedures.
42:2.0.1.2.9.8.35.6	SECTION 408.210	408.210 Termination of SMI premium surcharge agreement.
42:2.0.1.2.10	PART 409	PART 409 - HOSPITAL INSURANCE BENEFITS
42:2.0.1.2.10.1	SUBPART A	Subpart A - Hospital Insurance Benefits: General Provisions
42:2.0.1.2.10.1.35.1	SECTION 409.1	409.1 Statutory basis.
42:2.0.1.2.10.1.35.2	SECTION 409.2	409.2 Scope.
42:2.0.1.2.10.1.35.3	SECTION 409.3	409.3 Definitions.
42:2.0.1.2.10.1.35.4	SECTION 409.5	409.5 General description of benefits.
42:2.0.1.2.10.2	SUBPART B	Subpart B - Inpatient Hospital Services and Inpatient Critical Access Hospital Services
42:2.0.1.2.10.2.35.1	SECTION 409.10	409.10 Included services.
42:2.0.1.2.10.2.35.2	SECTION 409.11	409.11 Bed and board.
42:2.0.1.2.10.2.35.3	SECTION 409.12	409.12 Nursing and related services, medical social services; use of hospital or CAH facilities.
42:2.0.1.2.10.2.35.4	SECTION 409.13	409.13 Drugs and biologicals.
42:2.0.1.2.10.2.35.5	SECTION 409.14	409.14 Supplies, appliances, and equipment.
42:2.0.1.2.10.2.35.6	SECTION 409.15	409.15 Services furnished by an intern or a resident-in-training.
42:2.0.1.2.10.2.35.7	SECTION 409.16	409.16 Other diagnostic or therapeutic services.
42:2.0.1.2.10.2.35.8	SECTION 409.17	409.17 Physical therapy, occupational therapy, and speech-language pathology services.
42:2.0.1.2.10.2.35.9	SECTION 409.18	409.18 Services related to kidney transplantations.
42:2.0.1.2.10.3	SUBPART C	Subpart C - Posthospital SNF Care
42:2.0.1.2.10.3.35.1	SECTION 409.20	409.20 Coverage of services.
42:2.0.1.2.10.3.35.2	SECTION 409.21	409.21 Nursing care.
42:2.0.1.2.10.3.35.3	SECTION 409.22	409.22 Bed and board.
42:2.0.1.2.10.3.35.4	SECTION 409.23	409.23 Physical therapy, occupational therapy, and speech-language pathology services.
42:2.0.1.2.10.3.35.5	SECTION 409.24	409.24 Medical social services.
42:2.0.1.2.10.3.35.6	SECTION 409.25	409.25 Drugs, biologicals, supplies, appliances, and equipment.
42:2.0.1.2.10.3.35.7	SECTION 409.26	409.26 Transfer agreement hospital services.
42:2.0.1.2.10.3.35.8	SECTION 409.27	409.27 Other services generally provided by (or under arrangements made by) SNFs.
42:2.0.1.2.10.4	SUBPART D	Subpart D - Requirements for Coverage of Posthospital SNF Care
42:2.0.1.2.10.4.35.1	SECTION 409.30	409.30 Basic requirements.
42:2.0.1.2.10.4.35.2	SECTION 409.31	409.31 Level of care requirement.
42:2.0.1.2.10.4.35.3	SECTION 409.32	409.32 Criteria for skilled services and the need for skilled services.
42:2.0.1.2.10.4.35.4	SECTION 409.33	409.33 Examples of skilled nursing and rehabilitation services.
42:2.0.1.2.10.4.35.5	SECTION 409.34	409.34 Criteria for “daily basis”.
42:2.0.1.2.10.4.35.6	SECTION 409.35	409.35 Criteria for “practical matter”.
42:2.0.1.2.10.4.35.7	SECTION 409.36	409.36 Effect of discharge from posthospital SNF care.
42:2.0.1.2.10.5	SUBPART E	Subpart E - Home Health Services Under Hospital Insurance
42:2.0.1.2.10.5.35.1	SECTION 409.40	409.40 Basis, purpose, and scope.
42:2.0.1.2.10.5.35.2	SECTION 409.41	409.41 Requirement for payment.
42:2.0.1.2.10.5.35.3	SECTION 409.42	409.42 Beneficiary qualifications for coverage of services.
42:2.0.1.2.10.5.35.4	SECTION 409.43	409.43 Plan of care requirements.
42:2.0.1.2.10.5.35.5	SECTION 409.44	409.44 Skilled services requirements.
42:2.0.1.2.10.5.35.6	SECTION 409.45	409.45 Dependent services requirements.
42:2.0.1.2.10.5.35.7	SECTION 409.46	409.46 Allowable administrative costs.
42:2.0.1.2.10.5.35.8	SECTION 409.47	409.47 Place of service requirements.
42:2.0.1.2.10.5.35.9	SECTION 409.48	409.48 Visits.
42:2.0.1.2.10.5.35.10	SECTION 409.49	409.49 Excluded services.
42:2.0.1.2.10.5.35.11	SECTION 409.50	409.50 Coinsurance for durable medical equipment (DME) and applicable disposable devices furnished as a home health service.
42:2.0.1.2.10.6	SUBPART F	Subpart F - Scope of Hospital Insurance Benefits
42:2.0.1.2.10.6.35.1	SECTION 409.60	409.60 Benefit periods.
42:2.0.1.2.10.6.35.2	SECTION 409.61	409.61 General limitations on amount of benefits.
42:2.0.1.2.10.6.35.3	SECTION 409.62	409.62 Lifetime maximum on inpatient psychiatric care.
42:2.0.1.2.10.6.35.4	SECTION 409.63	409.63 Reduction of inpatient psychiatric benefit days available in the initial benefit period.
42:2.0.1.2.10.6.35.5	SECTION 409.64	409.64 Services that are counted toward allowable amounts.
42:2.0.1.2.10.6.35.6	SECTION 409.65	409.65 Lifetime reserve days.
42:2.0.1.2.10.6.35.7	SECTION 409.66	409.66 Revocation of election not to use lifetime reserve days.
42:2.0.1.2.10.6.35.8	SECTION 409.68	409.68 Guarantee of payment for inpatient hospital or inpatient CAH services furnished before notification of exhaustion of benefits.
42:2.0.1.2.10.7	SUBPART G	Subpart G - Hospital Insurance Deductibles and Coinsurance
42:2.0.1.2.10.7.35.1	SECTION 409.80	409.80 Inpatient deductible and coinsurance: General provisions.
42:2.0.1.2.10.7.35.2	SECTION 409.82	409.82 Inpatient hospital deductible.
42:2.0.1.2.10.7.35.3	SECTION 409.83	409.83 Inpatient hospital coinsurance.
42:2.0.1.2.10.7.35.4	SECTION 409.85	409.85 Skilled nursing facility (SNF) care coinsurance.
42:2.0.1.2.10.7.35.5	SECTION 409.87	409.87 Blood deductible.
42:2.0.1.2.10.7.35.6	SECTION 409.89	409.89 Exemption of kidney donors from deductible and coinsurance requirements.
42:2.0.1.2.10.8	SUBPART H	Subpart H - Payment of Hospital Insurance Benefits
42:2.0.1.2.10.8.35.1	SECTION 409.100	409.100 To whom payment is made.
42:2.0.1.2.10.8.35.2	SECTION 409.102	409.102 Amounts of payment.
42:2.0.1.2.11	PART 410	PART 410 - SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
42:2.0.1.2.11.1	SUBPART A	Subpart A - General Provisions
42:2.0.1.2.11.1.35.1	SECTION 410.1	410.1 Basis and scope.
42:2.0.1.2.11.1.35.2	SECTION 410.2	410.2 Definitions.
42:2.0.1.2.11.1.35.3	SECTION 410.3	410.3 Scope of benefits.
42:2.0.1.2.11.1.35.4	SECTION 410.5	410.5 Other applicable rules.
42:2.0.1.2.11.2	SUBPART B	Subpart B - Medical and Other Health Services
42:2.0.1.2.11.2.35.1	SECTION 410.10	410.10 Medical and other health services: Included services.
42:2.0.1.2.11.2.35.2	SECTION 410.12	410.12 Medical and other health services: Basic conditions and limitations.
42:2.0.1.2.11.2.35.3	SECTION 410.14	410.14 Special requirements for services furnished outside the United States.
42:2.0.1.2.11.2.35.4	SECTION 410.15	410.15 Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage.
42:2.0.1.2.11.2.35.5	SECTION 410.16	410.16 Initial preventive physical examination: Conditions for and limitations on coverage.
42:2.0.1.2.11.2.35.6	SECTION 410.17	410.17 Cardiovascular disease screening tests.
42:2.0.1.2.11.2.35.7	SECTION 410.18	410.18 Diabetes screening tests.
42:2.0.1.2.11.2.35.8	SECTION 410.19	410.19 Ultrasound screening for abdominal aortic aneurysms: Condition for and limitation on coverage.
42:2.0.1.2.11.2.35.9	SECTION 410.20	410.20 Physicians' services.
42:2.0.1.2.11.2.35.10	SECTION 410.21	410.21 Limitations on services of a chiropractor.
42:2.0.1.2.11.2.35.11	SECTION 410.22	410.22 Limitations on services of an optometrist.
42:2.0.1.2.11.2.35.12	SECTION 410.23	410.23 Screening for glaucoma: Conditions for and limitations on coverage.
42:2.0.1.2.11.2.35.13	SECTION 410.24	410.24 Limitations on services of a doctor of dental surgery or dental medicine.
42:2.0.1.2.11.2.35.14	SECTION 410.25	410.25 Limitations on services of a podiatrist.
42:2.0.1.2.11.2.35.15	SECTION 410.26	410.26 Services and supplies incident to a physician's professional services: Conditions.
42:2.0.1.2.11.2.35.16	SECTION 410.27	410.27 Therapeutic outpatient hospital or CAH services and supplies incident to a physician's or nonphysician practitioner's service: Conditions.
42:2.0.1.2.11.2.35.17	SECTION 410.28	410.28 Hospital or CAH diagnostic services furnished to outpatients: Conditions.
42:2.0.1.2.11.2.35.18	SECTION 410.29	410.29 Limitations on drugs and biologicals.
42:2.0.1.2.11.2.35.19	SECTION 410.30	410.30 Prescription drugs used in immunosuppressive therapy.
42:2.0.1.2.11.2.35.20	SECTION 410.31	410.31 Bone mass measurement: Conditions for coverage and frequency standards.
42:2.0.1.2.11.2.35.21	SECTION 410.32	410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
42:2.0.1.2.11.2.35.22	SECTION 410.33	410.33 Independent diagnostic testing facility.
42:2.0.1.2.11.2.35.23	SECTION 410.34	410.34 Mammography services: Conditions for and limitations on coverage.
42:2.0.1.2.11.2.35.24	SECTION 410.35	410.35 X-ray therapy and other radiation therapy services: Scope.
42:2.0.1.2.11.2.35.25	SECTION 410.36	410.36 Medical supplies, appliances, and devices: Scope.
42:2.0.1.2.11.2.35.26	SECTION 410.37	410.37 Colorectal cancer screening tests: Conditions for and limitations on coverage.
42:2.0.1.2.11.2.35.27	SECTION 410.38	410.38 Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions.
42:2.0.1.2.11.2.35.28	SECTION 410.39	410.39 Prostate cancer screening tests: Conditions for and limitations on coverage.
42:2.0.1.2.11.2.35.29	SECTION 410.40	410.40 Coverage of ambulance services.
42:2.0.1.2.11.2.35.30	SECTION 410.41	410.41 Requirements for ambulance providers and suppliers.
42:2.0.1.2.11.2.35.31	SECTION 410.42	410.42 Limitations on coverage of certain services furnished to hospital outpatients.
42:2.0.1.2.11.2.35.32	SECTION 410.43	410.43 Partial hospitalization services: Conditions and exclusions.
42:2.0.1.2.11.2.35.33	SECTION 410.45	410.45 Rural health clinic services: Scope and conditions.
42:2.0.1.2.11.2.35.34	SECTION 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.
42:2.0.1.2.11.2.35.35	SECTION 410.47	410.47 Pulmonary rehabilitation program: Conditions for coverage.
42:2.0.1.2.11.2.35.36	SECTION 410.48	410.48 Kidney disease education services.
42:2.0.1.2.11.2.35.37	SECTION 410.49	410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage.
42:2.0.1.2.11.2.35.38	SECTION 410.50	410.50 Institutional dialysis services and supplies: Scope and conditions.
42:2.0.1.2.11.2.35.39	SECTION 410.52	410.52 Home dialysis services, supplies, and equipment: Scope and conditions.
42:2.0.1.2.11.2.35.40	SECTION 410.55	410.55 Services related to kidney donations: Conditions.
42:2.0.1.2.11.2.35.41	SECTION 410.56	410.56 Screening pelvic examinations.
42:2.0.1.2.11.2.35.42	SECTION 410.57	410.57 Pneumococcal vaccine and flu vaccine.
42:2.0.1.2.11.2.35.43	SECTION 410.58	410.58 Additional services to HMO and CMP enrollees.
42:2.0.1.2.11.2.35.44	SECTION 410.59	410.59 Outpatient occupational therapy services: Conditions.
42:2.0.1.2.11.2.35.45	SECTION 410.60	410.60 Outpatient physical therapy services: Conditions.
42:2.0.1.2.11.2.35.46	SECTION 410.61	410.61 Plan of treatment requirements for outpatient rehabilitation services.
42:2.0.1.2.11.2.35.47	SECTION 410.62	410.62 Outpatient speech-language pathology services: Conditions and exclusions.
42:2.0.1.2.11.2.35.48	SECTION 410.63	410.63 Hepatitis B vaccine and blood clotting factors: Conditions.
42:2.0.1.2.11.2.35.49	SECTION 410.64	410.64 Additional preventive services.
42:2.0.1.2.11.2.35.50	SECTION 410.66	410.66 Emergency outpatient services furnished by a nonparticipating hospital and services furnished in a foreign country.
42:2.0.1.2.11.2.35.51	SECTION 410.67	410.67 Medicare coverage and payment of Opioid use disorder treatment services furnished by Opioid treatment programs.
42:2.0.1.2.11.2.35.52	SECTION 410.68	410.68 Antigens: Scope and conditions.
42:2.0.1.2.11.2.35.53	SECTION 410.69	410.69 Services of a certified registered nurse anesthetist or an anesthesiologist's assistant: Basic rule and definitions.
42:2.0.1.2.11.2.35.54	SECTION 410.71	410.71 Clinical psychologist services and services and supplies incident to clinical psychologist services.
42:2.0.1.2.11.2.35.55	SECTION 410.73	410.73 Clinical social worker services.
42:2.0.1.2.11.2.35.56	SECTION 410.74	410.74 Physician assistants' services.
42:2.0.1.2.11.2.35.57	SECTION 410.75	410.75 Nurse practitioners' services.
42:2.0.1.2.11.2.35.58	SECTION 410.76	410.76 Clinical nurse specialists' services.
42:2.0.1.2.11.2.35.59	SECTION 410.77	410.77 Certified nurse-midwives' services: Qualifications and conditions.
42:2.0.1.2.11.2.35.60	SECTION 410.78	410.78 Telehealth services.
42:2.0.1.2.11.2.35.61	SECTION 410.79	410.79 Medicare Diabetes Prevention Program expanded model: Conditions of coverage.
42:2.0.1.2.11.3	SUBPART C	Subpart C - Home Health Services Under SMI
42:2.0.1.2.11.3.35.1	SECTION 410.80	410.80 Applicable rules.
42:2.0.1.2.11.4	SUBPART D	Subpart D - Comprehensive Outpatient Rehabilitation Facility (CORF) Services
42:2.0.1.2.11.4.35.1	SECTION 410.100	410.100 Included services.
42:2.0.1.2.11.4.35.2	SECTION 410.102	410.102 Excluded services.
42:2.0.1.2.11.4.35.3	SECTION 410.105	410.105 Requirements for coverage of CORF services.
42:2.0.1.2.11.5	SUBPART E	Subpart E - Community Mental Health Centers (CMHCs) Providing Partial Hospitalization Services
42:2.0.1.2.11.5.35.1	SECTION 410.110	410.110 Requirements for coverage of partial hospitalization services by CMHCs.
42:2.0.1.2.11.6	SUBPART F	Subpart F [Reserved]
42:2.0.1.2.11.7	SUBPART G	Subpart G - Medical Nutrition Therapy
42:2.0.1.2.11.7.35.1	SECTION 410.130	410.130 Definitions.
42:2.0.1.2.11.7.35.2	SECTION 410.132	410.132 Medical nutrition therapy.
42:2.0.1.2.11.7.35.3	SECTION 410.134	410.134 Provider qualifications.
42:2.0.1.2.11.8	SUBPART H	Subpart H - Outpatient Diabetes Self-Management Training and Diabetes Outcome Measurements
42:2.0.1.2.11.8.35.1	SECTION 410.140	410.140 Definitions.
42:2.0.1.2.11.8.35.2	SECTION 410.141	410.141 Outpatient diabetes self-management training.
42:2.0.1.2.11.8.35.3	SECTION 410.142	410.142 CMS process for approving national accreditation organizations.
42:2.0.1.2.11.8.35.4	SECTION 410.143	410.143 Requirements for approved accreditation organizations.
42:2.0.1.2.11.8.35.5	SECTION 410.144	410.144 Quality standards for deemed entities.
42:2.0.1.2.11.8.35.6	SECTION 410.145	410.145 Requirements for entities.
42:2.0.1.2.11.8.35.7	SECTION 410.146	410.146 Diabetes outcome measurements.
42:2.0.1.2.11.9	SUBPART I	Subpart I - Payment of SMI Benefits
42:2.0.1.2.11.9.35.1	SECTION 410.150	410.150 To whom payment is made.
42:2.0.1.2.11.9.35.2	SECTION 410.152	410.152 Amounts of payment.
42:2.0.1.2.11.9.35.3	SECTION 410.155	410.155 Outpatient mental health treatment limitation.
42:2.0.1.2.11.9.35.4	SECTION 410.160	410.160 Part B annual deductible.
42:2.0.1.2.11.9.35.5	SECTION 410.161	410.161 Part B blood deductible.
42:2.0.1.2.11.9.35.6	SECTION 410.163	410.163 Payment for services furnished to kidney donors.
42:2.0.1.2.11.9.35.7	SECTION 410.165	410.165 Payment for rural health clinic services and ambulatory surgical center services: Conditions.
42:2.0.1.2.11.9.35.8	SECTION 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.
42:2.0.1.2.11.9.35.9	SECTION 410.172	410.172 Payment for partial hospitalization services in CMHCs: Conditions.
42:2.0.1.2.11.9.35.10	SECTION 410.175	410.175 Alien absent from the United States.
42:2.0.1.2.12	PART 411	PART 411 - EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
42:2.0.1.2.12.1	SUBPART A	Subpart A - General Exclusions and Exclusion of Particular Services
42:2.0.1.2.12.1.35.1	SECTION 411.1	411.1 Basis and scope.
42:2.0.1.2.12.1.35.2	SECTION 411.2	411.2 Conclusive effect of QIO determinations on payment of claims.
42:2.0.1.2.12.1.35.3	SECTION 411.4	411.4 Services for which neither the beneficiary nor any other person is legally obligated to pay.
42:2.0.1.2.12.1.35.4	SECTION 411.6	411.6 Services furnished by a Federal provider of services or other Federal agency.
42:2.0.1.2.12.1.35.5	SECTION 411.7	411.7 Services that must be furnished at public expense under a Federal law or Federal Government contract.
42:2.0.1.2.12.1.35.6	SECTION 411.8	411.8 Services paid for by a Government entity.
42:2.0.1.2.12.1.35.7	SECTION 411.9	411.9 Services furnished outside the United States.
42:2.0.1.2.12.1.35.8	SECTION 411.10	411.10 Services required as a result of war.
42:2.0.1.2.12.1.35.9	SECTION 411.12	411.12 Charges imposed by an immediate relative or member of the beneficiary's household.
42:2.0.1.2.12.1.35.10	SECTION 411.15	411.15 Particular services excluded from coverage.
42:2.0.1.2.12.2	SUBPART B	Subpart B - Insurance Coverage That Limits Medicare Payment: General Provisions
42:2.0.1.2.12.2.35.1	SECTION 411.20	411.20 Basis and scope.
42:2.0.1.2.12.2.35.2	SECTION 411.21	411.21 Definitions.
42:2.0.1.2.12.2.35.3	SECTION 411.22	411.22 Reimbursement obligations of primary payers and entities that received payment from primary payers.
42:2.0.1.2.12.2.35.4	SECTION 411.23	411.23 Beneficiary's cooperation.
42:2.0.1.2.12.2.35.5	SECTION 411.24	411.24 Recovery of conditional payments.
42:2.0.1.2.12.2.35.6	SECTION 411.25	411.25 Primary payer's notice of primary payment responsibility.
42:2.0.1.2.12.2.35.7	SECTION 411.26	411.26 Subrogation and right to intervene.
42:2.0.1.2.12.2.35.8	SECTION 411.28	411.28 Waiver of recovery and compromise of claims.
42:2.0.1.2.12.2.35.9	SECTION 411.30	411.30 Effect of primary payment on benefit utilization and deductibles.
42:2.0.1.2.12.2.35.10	SECTION 411.31	411.31 Authority to bill primary payers for full charges.
42:2.0.1.2.12.2.35.11	SECTION 411.32	411.32 Basis for Medicare secondary payments.
42:2.0.1.2.12.2.35.12	SECTION 411.33	411.33 Amount of Medicare secondary payment.
42:2.0.1.2.12.2.35.13	SECTION 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.
42:2.0.1.2.12.2.35.14	SECTION 411.37	411.37 Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.
42:2.0.1.2.12.2.35.15	SECTION 411.39	411.39 Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal.
42:2.0.1.2.12.3	SUBPART C	Subpart C - Limitations on Medicare Payment for Services Covered Under Workers' Compensation
42:2.0.1.2.12.3.35.1	SECTION 411.40	411.40 General provisions.
42:2.0.1.2.12.3.35.2	SECTION 411.43	411.43 Beneficiary's responsibility with respect to workers' compensation.
42:2.0.1.2.12.3.35.3	SECTION 411.45	411.45 Basis for conditional Medicare payment in workers' compensation cases.
42:2.0.1.2.12.3.35.4	SECTION 411.46	411.46 Lump-sum payments.
42:2.0.1.2.12.3.35.5	SECTION 411.47	411.47 Apportionment of a lump-sum compromise settlement of a workers' compensation claim.
42:2.0.1.2.12.4	SUBPART D	Subpart D - Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance
42:2.0.1.2.12.4.35.1	SECTION 411.50	411.50 General provisions.
42:2.0.1.2.12.4.35.2	SECTION 411.51	411.51 Beneficiary's responsibility with respect to no-fault insurance.
42:2.0.1.2.12.4.35.3	SECTION 411.52	411.52 Basis for conditional Medicare payment in liability cases.
42:2.0.1.2.12.4.35.4	SECTION 411.53	411.53 Basis for conditional Medicare payment in no-fault cases.
42:2.0.1.2.12.4.35.5	SECTION 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.
42:2.0.1.2.12.5	SUBPART E	Subpart E - Limitations on Payment for Services Covered Under Group Health Plans: General Provisions
42:2.0.1.2.12.5.35.1	SECTION 411.100	411.100 Basis and scope.
42:2.0.1.2.12.5.35.2	SECTION 411.101	411.101 Definitions.
42:2.0.1.2.12.5.35.3	SECTION 411.102	411.102 Basic prohibitions and requirements.
42:2.0.1.2.12.5.35.4	SECTION 411.103	411.103 Prohibition against financial and other incentives.
42:2.0.1.2.12.5.35.5	SECTION 411.104	411.104 Current employment status.
42:2.0.1.2.12.5.35.6	SECTION 411.106	411.106 Aggregation rules.
42:2.0.1.2.12.5.35.7	SECTION 411.108	411.108 Taking into account entitlement to Medicare.
42:2.0.1.2.12.5.35.8	SECTION 411.110	411.110 Basis for determination of nonconformance.
42:2.0.1.2.12.5.35.9	SECTION 411.112	411.112 Documentation of conformance.
42:2.0.1.2.12.5.35.10	SECTION 411.114	411.114 Determination of nonconformance.
42:2.0.1.2.12.5.35.11	SECTION 411.115	411.115 Notice of determination of nonconformance.
42:2.0.1.2.12.5.35.12	SECTION 411.120	411.120 Appeals.
42:2.0.1.2.12.5.35.13	SECTION 411.121	411.121 Hearing procedures.
42:2.0.1.2.12.5.35.14	SECTION 411.122	411.122 Hearing officer's decision.
42:2.0.1.2.12.5.35.15	SECTION 411.124	411.124 Administrator's review of hearing decision.
42:2.0.1.2.12.5.35.16	SECTION 411.126	411.126 Reopening of determinations and decisions.
42:2.0.1.2.12.5.35.17	SECTION 411.130	411.130 Referral to Internal Revenue Service (IRS).
42:2.0.1.2.12.6	SUBPART F	Subpart F - Special Rules: Individuals Eligible or Entitled on the Basis of ESRD, Who Are Also Covered Under Group Health Plans
42:2.0.1.2.12.6.35.1	SECTION 411.160	411.160 Scope.
42:2.0.1.2.12.6.35.2	SECTION 411.161	411.161 Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.
42:2.0.1.2.12.6.35.3	SECTION 411.162	411.162 Medicare benefits secondary to group health plan benefits.
42:2.0.1.2.12.6.35.4	SECTION 411.163	411.163 Coordination of benefits: Dual entitlement situations.
42:2.0.1.2.12.6.35.5	SECTION 411.165	411.165 Basis for conditional Medicare payments.
42:2.0.1.2.12.7	SUBPART G	Subpart G - Special Rules: Aged Beneficiaries and Spouses Who Are Also Covered Under Group Health Plans
42:2.0.1.2.12.7.35.1	SECTION 411.170	411.170 General provisions.
42:2.0.1.2.12.7.35.2	SECTION 411.172	411.172 Medicare benefits secondary to group health plan benefits.
42:2.0.1.2.12.7.35.3	SECTION 411.175	411.175 Basis for Medicare primary payments.
42:2.0.1.2.12.8	SUBPART H	Subpart H - Special Rules: Disabled Beneficiaries Who Are Also Covered Under Large Group Health Plans
42:2.0.1.2.12.8.35.1	SECTION 411.200	411.200 Basis.
42:2.0.1.2.12.8.35.2	SECTION 411.201	411.201 Definitions.
42:2.0.1.2.12.8.35.3	SECTION 411.204	411.204 Medicare benefits secondary to LGHP benefits.
42:2.0.1.2.12.8.35.4	SECTION 411.206	411.206 Basis for Medicare primary payments and limits on secondary payments.
42:2.0.1.2.12.9	SUBPART I	Subpart I [Reserved]
42:2.0.1.2.12.10	SUBPART J	Subpart J - Financial Relationships Between Physicians and Entities Furnishing Designated Health Services
42:2.0.1.2.12.10.35.1	SECTION 411.350	411.350 Scope of subpart.
42:2.0.1.2.12.10.35.2	SECTION 411.351	411.351 Definitions.
42:2.0.1.2.12.10.35.3	SECTION 411.352	411.352 Group practice.
42:2.0.1.2.12.10.35.4	SECTION 411.353	411.353 Prohibition on certain referrals by physicians and limitations on billing.
42:2.0.1.2.12.10.35.5	SECTION 411.354	411.354 Financial relationship, compensation, and ownership or investment interest.
42:2.0.1.2.12.10.35.6	SECTION 411.355	411.355 General exceptions to the referral prohibition related to both ownership/investment and compensation.
42:2.0.1.2.12.10.35.7	SECTION 411.356	411.356 Exceptions to the referral prohibition related to ownership or investment interests.
42:2.0.1.2.12.10.35.8	SECTION 411.357	411.357 Exceptions to the referral prohibition related to compensation arrangements.
42:2.0.1.2.12.10.35.9	SECTION 411.361	411.361 Reporting requirements.
42:2.0.1.2.12.10.35.10	SECTION 411.362	411.362 Additional requirements concerning physician ownership and investment in hospitals.
42:2.0.1.2.12.10.35.11	SECTION 411.370	411.370 Advisory opinions relating to physician referrals.
42:2.0.1.2.12.10.35.12	SECTION 411.372	411.372 Procedure for submitting a request.
42:2.0.1.2.12.10.35.13	SECTION 411.373	411.373 Certification.
42:2.0.1.2.12.10.35.14	SECTION 411.375	411.375 Fees for the cost of advisory opinions.
42:2.0.1.2.12.10.35.15	SECTION 411.377	411.377 Expert opinions from outside sources.
42:2.0.1.2.12.10.35.16	SECTION 411.378	411.378 Withdrawing a request.
42:2.0.1.2.12.10.35.17	SECTION 411.379	411.379 When CMS accepts a request.
42:2.0.1.2.12.10.35.18	SECTION 411.380	411.380 When CMS issues a formal advisory opinion.
42:2.0.1.2.12.10.35.19	SECTION 411.382	411.382 CMS' right to rescind advisory opinions.
42:2.0.1.2.12.10.35.20	SECTION 411.384	411.384 Disclosing advisory opinions and supporting information.
42:2.0.1.2.12.10.35.21	SECTION 411.386	411.386 CMS's advisory opinions as exclusive.
42:2.0.1.2.12.10.35.22	SECTION 411.387	411.387 Effect of an advisory opinion.
42:2.0.1.2.12.10.35.23	SECTION 411.388	411.388 When advisory opinions are not admissible evidence.
42:2.0.1.2.12.10.35.24	SECTION 411.389	411.389 Range of the advisory opinion.
42:2.0.1.2.12.11	SUBPART K	Subpart K - Payment for Certain Excluded Services
42:2.0.1.2.12.11.35.1	SECTION 411.400	411.400 Payment for custodial care and services not reasonable and necessary.
42:2.0.1.2.12.11.35.2	SECTION 411.402	411.402 Indemnification of beneficiary.
42:2.0.1.2.12.11.35.3	SECTION 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.
42:2.0.1.2.12.11.35.4	SECTION 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.
42:2.0.1.2.12.11.35.5	SECTION 411.408	411.408 Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.
42:2.0.1.2.13	PART 412	PART 412 - PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
42:2.0.1.2.13.1	SUBPART A	Subpart A - General Provisions
42:2.0.1.2.13.1.48.1	SECTION 412.1	412.1 Scope of part.
42:2.0.1.2.13.1.48.2	SECTION 412.2	412.2 Basis of payment.
42:2.0.1.2.13.1.48.3	SECTION 412.3	412.3 Admissions.
42:2.0.1.2.13.1.48.4	SECTION 412.4	412.4 Discharges and transfers.
42:2.0.1.2.13.1.48.5	SECTION 412.6	412.6 Cost reporting periods subject to the prospective payment systems.
42:2.0.1.2.13.1.48.6	SECTION 412.8	412.8 Publication of schedules for determining prospective payment rates.
42:2.0.1.2.13.1.48.7	SECTION 412.10	412.10 Changes in the DRG classification system.
42:2.0.1.2.13.2	SUBPART B	Subpart B - Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
42:2.0.1.2.13.2.48.1	SECTION 412.20	412.20 Hospital services subject to the prospective payment systems.
42:2.0.1.2.13.2.48.2	SECTION 412.22	412.22 Excluded hospitals and hospital units: General rules.
42:2.0.1.2.13.2.48.3	SECTION 412.23	412.23 Excluded hospitals: Classifications.
42:2.0.1.2.13.2.48.4	SECTION 412.25	412.25 Excluded hospital units: Common requirements.
42:2.0.1.2.13.2.48.5	SECTION 412.27	412.27 Excluded psychiatric units: Additional requirements.
42:2.0.1.2.13.2.48.6	SECTION 412.29	412.29 Classification criteria for payment under the inpatient rehabilitation facility prospective payment system.
42:2.0.1.2.13.2.48.7	SECTION 412.30	412.30 [Reserved]
42:2.0.1.2.13.3	SUBPART C	Subpart C - Conditions for Payment Under the Prospective Payment Systems for Inpatient Operating Costs and Inpatient Capital-Related Costs
42:2.0.1.2.13.3.48.1	SECTION 412.40	412.40 General requirements.
42:2.0.1.2.13.3.48.2	SECTION 412.42	412.42 Limitations on charges to beneficiaries.
42:2.0.1.2.13.3.48.3	SECTION 412.44	412.44 Medical review requirements: Admissions and quality review.
42:2.0.1.2.13.3.48.4	SECTION 412.46	412.46 Medical review requirements.
42:2.0.1.2.13.3.48.5	SECTION 412.48	412.48 Denial of payment as a result of admissions and quality review.
42:2.0.1.2.13.3.48.6	SECTION 412.50	412.50 Furnishing of inpatient hospital services directly or under arrangements.
42:2.0.1.2.13.3.48.7	SECTION 412.52	412.52 Reporting and recordkeeping requirements.
42:2.0.1.2.13.4	SUBPART D	Subpart D - Basic Methodology for Determining Prospective Payment Federal Rates for Inpatient Operating Costs
42:2.0.1.2.13.4.48.1	SECTION 412.60	412.60 DRG classification and weighting factors.
42:2.0.1.2.13.4.48.2	SECTION 412.62	412.62 Federal rates for inpatient operating costs for fiscal year 1984.
42:2.0.1.2.13.4.48.3	SECTION 412.63	412.63 Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004.
42:2.0.1.2.13.4.48.4	SECTION 412.64	412.64 Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.
42:2.0.1.2.13.5	SUBPART E	Subpart E - Determination of Transition Period Payment Rates for the Prospective Payment System for Inpatient Operating Costs
42:2.0.1.2.13.5.48.1	SECTION 412.70	412.70 General description.
42:2.0.1.2.13.5.48.2	SECTION 412.71	412.71 Determination of base-year inpatient operating costs.
42:2.0.1.2.13.5.48.3	SECTION 412.72	412.72 Modification of base-year costs.
42:2.0.1.2.13.5.48.4	SECTION 412.73	412.73 Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.
42:2.0.1.2.13.5.48.5	SECTION 412.75	412.75 Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.
42:2.0.1.2.13.5.48.6	SECTION 412.76	412.76 Recovery of excess transition period payment amounts resulting from unlawful claims.
42:2.0.1.2.13.5.48.7	SECTION 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.
42:2.0.1.2.13.5.48.8	SECTION 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.
42:2.0.1.2.13.5.48.9	SECTION 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.
42:2.0.1.2.13.6	SUBPART F	Subpart F - Payments for Outlier Cases, Special Treatment Payment for New Technology, and Payment Adjustment for Certain Replaced Devices
42:2.0.1.2.13.6.48	SUBJGRP 48	Payment for Outlier Cases
42:2.0.1.2.13.6.48.1	SECTION 412.80	412.80 Outlier cases: General provisions.
42:2.0.1.2.13.6.48.2	SECTION 412.82	412.82 Payment for extended length-of-stay cases (day outliers).
42:2.0.1.2.13.6.48.3	SECTION 412.84	412.84 Payment for extraordinarily high-cost cases (cost outliers).
42:2.0.1.2.13.6.49	SUBJGRP 49	Payment Adjustment for Certain Clinical Trial Cases and Expanded Access Use Immunotherapy
42:2.0.1.2.13.6.49.4	SECTION 412.85	412.85 Payment adjustment for certain clinical trial and expanded access use immunotherapy cases.
42:2.0.1.2.13.6.49.5	SECTION 412.83	412.83 Payment for extraordinarily high-cost day outliers.
42:2.0.1.2.13.6.49.6	SECTION 412.86	412.86 [Reserved]
42:2.0.1.2.13.6.50	SUBJGRP 50	Additional Special Payment for Certain New Technology
42:2.0.1.2.13.6.50.7	SECTION 412.87	412.87 Additional payment for new medical services and technologies: General provisions.
42:2.0.1.2.13.6.50.8	SECTION 412.88	412.88 Additional payment for new medical service or technology.
42:2.0.1.2.13.6.51	SUBJGRP 51	Payment Adjustment for Certain Replaced Devices
42:2.0.1.2.13.6.51.9	SECTION 412.89	412.89 Payment adjustment for certain replaced devices.
42:2.0.1.2.13.7	SUBPART G	Subpart G - Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs
42:2.0.1.2.13.7.52.1	SECTION 412.90	412.90 General rules.
42:2.0.1.2.13.7.52.2	SECTION 412.92	412.92 Special treatment: Sole community hospitals.
42:2.0.1.2.13.7.52.3	SECTION 412.96	412.96 Special treatment: Referral centers.
42:2.0.1.2.13.7.52.4	SECTION 412.98	412.98 [Reserved]
42:2.0.1.2.13.7.52.5	SECTION 412.100	412.100 Special treatment: Renal transplantation centers.
42:2.0.1.2.13.7.52.6	SECTION 412.101	412.101 Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.
42:2.0.1.2.13.7.52.7	SECTION 412.102	412.102 Special treatment: Hospitals located in areas that are changing from urban to rural as a result of a geographic redesignation.
42:2.0.1.2.13.7.52.8	SECTION 412.103	412.103 Special treatment: Hospitals located in urban areas and that apply for reclassification as rural.
42:2.0.1.2.13.7.52.9	SECTION 412.104	412.104 Special treatment: Hospitals with high percentage of ESRD discharges.
42:2.0.1.2.13.7.52.10	SECTION 412.105	412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
42:2.0.1.2.13.7.52.11	SECTION 412.106	412.106 Special treatment: Hospitals that serve a disproportionate share of low-income patients.
42:2.0.1.2.13.7.52.12	SECTION 412.107	412.107 Special treatment: Hospitals that receive an additional update for FYs 1998 and 1999.
42:2.0.1.2.13.7.52.13	SECTION 412.108	412.108 Special treatment: Medicare-dependent, small rural hospitals.
42:2.0.1.2.13.7.52.14	SECTION 412.109	412.109 Special treatment: Essential access community hospitals (EACHs).
42:2.0.1.2.13.8	SUBPART H	Subpart H - Payments to Hospitals Under the Prospective Payment Systems
42:2.0.1.2.13.8.52.1	SECTION 412.110	412.110 Total Medicare payment.
42:2.0.1.2.13.8.52.2	SECTION 412.112	412.112 Payments determined on a per case basis.
42:2.0.1.2.13.8.52.3	SECTION 412.113	412.113 Other payments.
42:2.0.1.2.13.8.52.4	SECTION 412.115	412.115 Additional payments.
42:2.0.1.2.13.8.52.5	SECTION 412.116	412.116 Method of payment.
42:2.0.1.2.13.8.52.6	SECTION 412.120	412.120 Reductions to total payments.
42:2.0.1.2.13.8.52.7	SECTION 412.125	412.125 Effect of change of ownership on payments under the prospective payment systems.
42:2.0.1.2.13.8.52.8	SECTION 412.130	412.130 Retroactive adjustments for incorrectly excluded hospitals and units.
42:2.0.1.2.13.8.52.9	SECTION 412.140	412.140 Participation, data submission, and validation requirements under the Hospital Inpatient Quality Reporting (IQR) Program.
42:2.0.1.2.13.9	SUBPART I	Subpart I - Adjustments to the Base Operating DRG Payment Amounts Under the Prospective Payment Systems for Inpatient Operating Costs
42:2.0.1.2.13.9.52	SUBJGRP 52	Payment Adjustments Under the Hospital Readmissions Reduction Program
42:2.0.1.2.13.9.52.1	SECTION 412.150	412.150 Basis and scope of subpart.
42:2.0.1.2.13.9.52.2	SECTION 412.152	412.152 Definitions for the Hospital Readmissions Reduction Program.
42:2.0.1.2.13.9.52.3	SECTION 412.154	412.154 Payment adjustments under the Hospital Readmissions Reduction Program.
42:2.0.1.2.13.9.52.4	SECTION 412.155-412.159	412.155-412.159 [Reserved]
42:2.0.1.2.13.9.53	SUBJGRP 53	Incentive Payments Under the Hospital Value-Based Purchasing Program
42:2.0.1.2.13.9.53.5	SECTION 412.160	412.160 Definitions for the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.13.9.53.6	SECTION 412.161	412.161 Applicability of the Hospital Value-Based Purchasing (VBP) Program
42:2.0.1.2.13.9.53.7	SECTION 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.
42:2.0.1.2.13.9.53.8	SECTION 412.163	412.163 Process for making hospital-specific performance information under the Hospital Value-Based Purchasing (VBP) Program available to the public.
42:2.0.1.2.13.9.53.9	SECTION 412.164	412.164 Measure selection under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.13.9.53.10	SECTION 412.165	412.165 Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.13.9.53.11	SECTION 412.167	412.167 Appeal under the Hospital Value-Based Purchasing (VBP) Program.
42:2.0.1.2.13.9.53.12	SECTION 412.168-412.169	412.168-412.169 [Reserved]
42:2.0.1.2.13.9.54	SUBJGRP 54	Payment Adjustments Under the Hospital-Acquired Condition Reduction Program
42:2.0.1.2.13.9.54.13	SECTION 412.170	412.170 Definitions for the Hospital-Acquired Condition Reduction Program.
42:2.0.1.2.13.9.54.14	SECTION 412.172	412.172 Payment adjustments under the Hospital-Acquired Condition Reduction Program.
42:2.0.1.2.13.9.54.15	SECTION 412.190	412.190 Overall Hospital Quality Star Rating.
42:2.0.1.2.13.10	SUBPART J	Subpart J [Reserved]
42:2.0.1.2.13.11	SUBPART K	Subpart K - Prospective Payment System for Inpatient Operating Costs for Hospitals Located in Puerto Rico
42:2.0.1.2.13.11.55.1	SECTION 412.200	412.200 General provisions.
42:2.0.1.2.13.11.55.2	SECTION 412.204	412.204 Payment to hospitals located in Puerto Rico.
42:2.0.1.2.13.11.55.3	SECTION 412.208	412.208 Puerto Rico rates for Federal fiscal year 1988.
42:2.0.1.2.13.11.55.4	SECTION 412.210	412.210 Puerto Rico rates for Federal fiscal years 1989 through 2003.
42:2.0.1.2.13.11.55.5	SECTION 412.211	412.211 Puerto Rico rates for Federal fiscal year 2004 and subsequent fiscal years.
42:2.0.1.2.13.11.55.6	SECTION 412.212	412.212 National rate.
42:2.0.1.2.13.11.55.7	SECTION 412.220	412.220 Special treatment of certain hospitals located in Puerto Rico.
42:2.0.1.2.13.12	SUBPART L	Subpart L - The Medicare Geographic Classification Review Board
42:2.0.1.2.13.12.55	SUBJGRP 55	Criteria and Conditions for Redesignation
42:2.0.1.2.13.12.55.1	SECTION 412.230	412.230 Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
42:2.0.1.2.13.12.55.2	SECTION 412.232	412.232 Criteria for all hospitals in a rural county seeking urban redesignation.
42:2.0.1.2.13.12.55.3	SECTION 412.234	412.234 Criteria for all hospitals in an urban county seeking redesignation to another urban area.
42:2.0.1.2.13.12.55.4	SECTION 412.235	412.235 Criteria for all hospitals in a State seeking a statewide wage index redesignation.
42:2.0.1.2.13.12.56	SUBJGRP 56	Composition and Procedures
42:2.0.1.2.13.12.56.5	SECTION 412.246	412.246 MGCRB members.
42:2.0.1.2.13.12.56.6	SECTION 412.248	412.248 Number of members needed for a decision or a hearing.
42:2.0.1.2.13.12.56.7	SECTION 412.250	412.250 Sources of MGCRB's authority.
42:2.0.1.2.13.12.56.8	SECTION 412.252	412.252 Applications.
42:2.0.1.2.13.12.56.9	SECTION 412.254	412.254 Proceedings before MGCRB.
42:2.0.1.2.13.12.56.10	SECTION 412.256	412.256 Application requirements.
42:2.0.1.2.13.12.56.11	SECTION 412.258	412.258 Parties to MGCRB proceeding.
42:2.0.1.2.13.12.56.12	SECTION 412.260	412.260 Time and place of the oral hearing.
42:2.0.1.2.13.12.56.13	SECTION 412.262	412.262 Disqualification of an MGCRB member.
42:2.0.1.2.13.12.56.14	SECTION 412.264	412.264 Evidence and comments in MGCRB proceeding.
42:2.0.1.2.13.12.56.15	SECTION 412.266	412.266 Availability of wage data.
42:2.0.1.2.13.12.56.16	SECTION 412.268	412.268 Subpoenas.
42:2.0.1.2.13.12.56.17	SECTION 412.270	412.270 Witnesses.
42:2.0.1.2.13.12.56.18	SECTION 412.272	412.272 Record of proceedings before the MGCRB.
42:2.0.1.2.13.12.56.19	SECTION 412.273	412.273 Withdrawing an application, terminating an approved 3-year reclassification, or canceling a previous withdrawal or termination.
42:2.0.1.2.13.12.56.20	SECTION 412.274	412.274 Scope and effect of an MGCRB decision.
42:2.0.1.2.13.12.56.21	SECTION 412.276	412.276 Timing of MGCRB decision and its appeal.
42:2.0.1.2.13.12.56.22	SECTION 412.278	412.278 Administrator's review.
42:2.0.1.2.13.12.56.23	SECTION 412.280	412.280 Representation.
42:2.0.1.2.13.13	SUBPART M	Subpart M - Prospective Payment System for Inpatient Hospital Capital Costs
42:2.0.1.2.13.13.57	SUBJGRP 57	General Provisions
42:2.0.1.2.13.13.57.1	SECTION 412.300	412.300 Scope of subpart and definition.
42:2.0.1.2.13.13.57.2	SECTION 412.302	412.302 Introduction to capital costs.
42:2.0.1.2.13.13.57.3	SECTION 412.304	412.304 Implementation of the capital prospective payment system.
42:2.0.1.2.13.13.58	SUBJGRP 58	Basic Methodology for Determining the Federal Rate for Capital-Related Costs
42:2.0.1.2.13.13.58.4	SECTION 412.308	412.308 Determining and updating the Federal rate.
42:2.0.1.2.13.13.58.5	SECTION 412.312	412.312 Payment based on the Federal rate.
42:2.0.1.2.13.13.58.6	SECTION 412.316	412.316 Geographic adjustment factors.
42:2.0.1.2.13.13.58.7	SECTION 412.320	412.320 Disproportionate share adjustment factor.
42:2.0.1.2.13.13.58.8	SECTION 412.322	412.322 Indirect medical education adjustment factor.
42:2.0.1.2.13.13.59	SUBJGRP 59	Determination of Transition Period Payment Rates for Capital-Related Costs
42:2.0.1.2.13.13.59.9	SECTION 412.324	412.324 General description.
42:2.0.1.2.13.13.59.10	SECTION 412.328	412.328 Determining and updating the hospital-specific rate.
42:2.0.1.2.13.13.59.11	SECTION 412.331	412.331 Determining hospital-specific rates in cases of hospital merger, consolidation, or dissolution.
42:2.0.1.2.13.13.59.12	SECTION 412.332	412.332 Payment based on the hospital-specific rate.
42:2.0.1.2.13.13.59.13	SECTION 412.336	412.336 Transition period payment methodologies.
42:2.0.1.2.13.13.59.14	SECTION 412.340	412.340 Fully prospective payment methodology.
42:2.0.1.2.13.13.59.15	SECTION 412.344	412.344 Hold-harmless payment methodology.
42:2.0.1.2.13.13.59.16	SECTION 412.348	412.348 Exception payments.
42:2.0.1.2.13.13.59.17	SECTION 412.352	412.352 Budget neutrality adjustment.
42:2.0.1.2.13.13.60	SUBJGRP 60	Special Rules for Puerto Rico Hospitals
42:2.0.1.2.13.13.60.18	SECTION 412.370	412.370 General provisions for hospitals located in Puerto Rico.
42:2.0.1.2.13.13.60.19	SECTION 412.374	412.374 Payments to hospitals located in Puerto Rico.
42:2.0.1.2.13.14	SUBPART N	Subpart N - Prospective Payment System for Inpatient Hospital Services of Inpatient Psychiatric Facilities
42:2.0.1.2.13.14.61.1	SECTION 412.400	412.400 Basis and scope of subpart.
42:2.0.1.2.13.14.61.2	SECTION 412.402	412.402 Definitions.
42:2.0.1.2.13.14.61.3	SECTION 412.404	412.404 Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities.
42:2.0.1.2.13.14.61.4	SECTION 412.405	412.405 Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system.
42:2.0.1.2.13.14.61.5	SECTION 412.422	412.422 Basis of payment.
42:2.0.1.2.13.14.61.6	SECTION 412.424	412.424 Methodology for calculating the Federal per diem payment amount.
42:2.0.1.2.13.14.61.7	SECTION 412.426	412.426 Transition period.
42:2.0.1.2.13.14.61.8	SECTION 412.428	412.428 Publication of changes to the inpatient psychiatric facility prospective payment system.
42:2.0.1.2.13.14.61.9	SECTION 412.432	412.432 Method of payment under the inpatient psychiatric facility prospective payment system.
42:2.0.1.2.13.14.61.10	SECTION 412.434	412.434 Reconsideration and appeals procedures of Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program decisions.
42:2.0.1.2.13.15	SUBPART O	Subpart O - Prospective Payment System for Long-Term Care Hospitals
42:2.0.1.2.13.15.61.1	SECTION 412.500	412.500 Basis and scope of subpart.
42:2.0.1.2.13.15.61.2	SECTION 412.503	412.503 Definitions.
42:2.0.1.2.13.15.61.3	SECTION 412.505	412.505 Conditions for payment under the prospective payment system for long-term care hospitals.
42:2.0.1.2.13.15.61.4	SECTION 412.507	412.507 Limitation on charges to beneficiaries.
42:2.0.1.2.13.15.61.5	SECTION 412.508	412.508 Medical review requirements.
42:2.0.1.2.13.15.61.6	SECTION 412.509	412.509 Furnishing of inpatient hospital services directly or under arrangement.
42:2.0.1.2.13.15.61.7	SECTION 412.511	412.511 Reporting and recordkeeping requirements.
42:2.0.1.2.13.15.61.8	SECTION 412.513	412.513 Patient classification system.
42:2.0.1.2.13.15.61.9	SECTION 412.515	412.515 LTC-DRG weighting factors.
42:2.0.1.2.13.15.61.10	SECTION 412.517	412.517 Revision of LTC-DRG group classifications and weighting factors.
42:2.0.1.2.13.15.61.11	SECTION 412.521	412.521 Basis of payment.
42:2.0.1.2.13.15.61.12	SECTION 412.522	412.522 Application of site neutral payment rate.
42:2.0.1.2.13.15.61.13	SECTION 412.523	412.523 Methodology for calculating the Federal prospective payment rates.
42:2.0.1.2.13.15.61.14	SECTION 412.525	412.525 Adjustments to the Federal prospective payment.
42:2.0.1.2.13.15.61.15	SECTION 412.526	412.526 Payment provisions for a “subclause (II)” long-term care hospital.
42:2.0.1.2.13.15.61.16	SECTION 412.529	412.529 Special payment provision for short-stay outliers.
42:2.0.1.2.13.15.61.17	SECTION 412.531	412.531 Special payment provisions when an interruption of a stay occurs in a long-term care hospital.
42:2.0.1.2.13.15.61.18	SECTION 412.533	412.533 Transition payments.
42:2.0.1.2.13.15.61.19	SECTION 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.
42:2.0.1.2.13.15.61.20	SECTION 412.535	412.535 Publication of the Federal prospective payment rates.
42:2.0.1.2.13.15.61.21	SECTION 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 satellite of the long-term care hospital, effective for discharges occurring on or before September 30, 2016 or in cost reporting periods beginning on or before June 30, 2016.
42:2.0.1.2.13.15.61.22	SECTION 412.538	412.538 [Reserved]
42:2.0.1.2.13.15.61.23	SECTION 412.540	412.540 Method of payment for preadmission services under the long-term care hospital prospective payment system.
42:2.0.1.2.13.15.61.24	SECTION 412.541	412.541 Method of payment under the long-term care hospital prospective payment system.
42:2.0.1.2.13.15.61.25	SECTION 412.560	412.560 Requirements under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP).
42:2.0.1.2.13.16	SUBPART P	Subpart P - Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units
42:2.0.1.2.13.16.61.1	SECTION 412.600	412.600 Basis and scope of subpart.
42:2.0.1.2.13.16.61.2	SECTION 412.602	412.602 Definitions.
42:2.0.1.2.13.16.61.3	SECTION 412.604	412.604 Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.
42:2.0.1.2.13.16.61.4	SECTION 412.606	412.606 Patient assessments.
42:2.0.1.2.13.16.61.5	SECTION 412.608	412.608 Patients' rights regarding the collection of patient assessment data.
42:2.0.1.2.13.16.61.6	SECTION 412.610	412.610 Assessment schedule.
42:2.0.1.2.13.16.61.7	SECTION 412.612	412.612 Coordination of the collection of patient assessment data.
42:2.0.1.2.13.16.61.8	SECTION 412.614	412.614 Transmission of patient assessment data.
42:2.0.1.2.13.16.61.9	SECTION 412.616	412.616 Release of information collected using the patient assessment instrument.
42:2.0.1.2.13.16.61.10	SECTION 412.618	412.618 Assessment process for interrupted stays.
42:2.0.1.2.13.16.61.11	SECTION 412.620	412.620 Patient classification system.
42:2.0.1.2.13.16.61.12	SECTION 412.622	412.622 Basis of payment.
42:2.0.1.2.13.16.61.13	SECTION 412.624	412.624 Methodology for calculating the Federal prospective payment rates.
42:2.0.1.2.13.16.61.14	SECTION 412.626	412.626 Transition period.
42:2.0.1.2.13.16.61.15	SECTION 412.628	412.628 Publication of the Federal prospective payment rates.
42:2.0.1.2.13.16.61.16	SECTION 412.630	412.630 Limitation on review.
42:2.0.1.2.13.16.61.17	SECTION 412.632	412.632 Method of payment under the inpatient rehabilitation facility prospective payment system.
42:2.0.1.2.13.16.61.18	SECTION 412.634	412.634 Requirements under the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP).
42:2.0.1.2.14	PART 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
42:2.0.1.2.14.1	SUBPART A	Subpart A - Introduction and General Rules
42:2.0.1.2.14.1.61.1	SECTION 413.1	413.1 Introduction.
42:2.0.1.2.14.1.61.2	SECTION 413.5	413.5 Cost reimbursement: General.
42:2.0.1.2.14.1.61.3	SECTION 413.9	413.9 Cost related to patient care.
42:2.0.1.2.14.1.61.4	SECTION 413.13	413.13 Amount of payment if customary charges for services furnished are less than reasonable costs.
42:2.0.1.2.14.1.61.5	SECTION 413.17	413.17 Cost to related organizations.
42:2.0.1.2.14.2	SUBPART B	Subpart B - Accounting Records and Reports
42:2.0.1.2.14.2.61.1	SECTION 413.20	413.20 Financial data and reports.
42:2.0.1.2.14.2.61.2	SECTION 413.24	413.24 Adequate cost data and cost finding.
42:2.0.1.2.14.3	SUBPART C	Subpart C - Limits on Cost Reimbursement
42:2.0.1.2.14.3.61.1	SECTION 413.30	413.30 Limitations on payable costs.
42:2.0.1.2.14.3.61.2	SECTION 413.35	413.35 Limitations on coverage of costs: Charges to beneficiaries if cost limits are applied to services.
42:2.0.1.2.14.3.61.3	SECTION 413.40	413.40 Ceiling on the rate of increase in hospital inpatient costs.
42:2.0.1.2.14.4	SUBPART D	Subpart D - Apportionment
42:2.0.1.2.14.4.61.1	SECTION 413.50	413.50 Apportionment of allowable costs.
42:2.0.1.2.14.4.61.2	SECTION 413.53	413.53 Determination of cost of services to beneficiaries.
42:2.0.1.2.14.4.61.3	SECTION 413.56	413.56 [Reserved]
42:2.0.1.2.14.5	SUBPART E	Subpart E - Payments to Providers
42:2.0.1.2.14.5.61.1	SECTION 413.60	413.60 Payments to providers: General.
42:2.0.1.2.14.5.61.2	SECTION 413.64	413.64 Payments to providers: Specific rules.
42:2.0.1.2.14.5.61.3	SECTION 413.65	413.65 Requirements for a determination that a facility or an organization has provider-based status.
42:2.0.1.2.14.5.61.4	SECTION 413.70	413.70 Payment for services of a CAH.
42:2.0.1.2.14.5.61.5	SECTION 413.74	413.74 Payment to a foreign hospital.
42:2.0.1.2.14.6	SUBPART F	Subpart F - Specific Categories of Costs
42:2.0.1.2.14.6.61.1	SECTION 413.75	413.75 Direct GME payments: General requirements.
42:2.0.1.2.14.6.61.2	SECTION 413.76	413.76 Direct GME payments: Calculation of payments for GME costs.
42:2.0.1.2.14.6.61.3	SECTION 413.77	413.77 Direct GME payments: Determination of per resident amounts.
42:2.0.1.2.14.6.61.4	SECTION 413.78	413.78 Direct GME payments: Determination of the total number of FTE residents.
42:2.0.1.2.14.6.61.5	SECTION 413.79	413.79 Direct GME payments: Determination of the weighted number of FTE residents.
42:2.0.1.2.14.6.61.6	SECTION 413.80	413.80 Direct GME payments: Determination of weighting factors for foreign medical graduates.
42:2.0.1.2.14.6.61.7	SECTION 413.81	413.81 Direct GME payments: Application of community support and redistribution of costs in determining FTE resident counts.
42:2.0.1.2.14.6.61.8	SECTION 413.82	413.82 Direct GME payments: Special rules for States that formerly had a waiver from Medicare reimbursement principles.
42:2.0.1.2.14.6.61.9	SECTION 413.83	413.83 Direct GME payments: Adjustment of a hospital's target amount or prospective payment hospital-specific rate.
42:2.0.1.2.14.6.61.10	SECTION 413.85	413.85 Cost of approved nursing and allied health education activities.
42:2.0.1.2.14.6.61.11	SECTION 413.87	413.87 Payments for Medicare + Choice nursing and allied health education programs.
42:2.0.1.2.14.6.61.12	SECTION 413.88	413.88 Incentive payments under plans for voluntary reduction in number of medical residents.
42:2.0.1.2.14.6.61.13	SECTION 413.89	413.89 Bad debts, charity, and courtesy allowances.
42:2.0.1.2.14.6.61.14	SECTION 413.90	413.90 Research costs.
42:2.0.1.2.14.6.61.15	SECTION 413.92	413.92 Costs of surety bonds.
42:2.0.1.2.14.6.61.16	SECTION 413.94	413.94 Value of services of nonpaid workers.
42:2.0.1.2.14.6.61.17	SECTION 413.98	413.98 Purchase discounts and allowances, and refunds of expenses.
42:2.0.1.2.14.6.61.18	SECTION 413.100	413.100 Special treatment of certain accrued costs.
42:2.0.1.2.14.6.61.19	SECTION 413.102	413.102 Compensation of owners.
42:2.0.1.2.14.6.61.20	SECTION 413.106	413.106 Reasonable cost of physical and other therapy services furnished under arrangements.
42:2.0.1.2.14.6.61.21	SECTION 413.114	413.114 Payment for posthospital SNF care furnished by a swing-bed hospital.
42:2.0.1.2.14.6.61.22	SECTION 413.118	413.118 Payment for facility services related to covered ASC surgical procedures performed in hospitals on an outpatient basis.
42:2.0.1.2.14.6.61.23	SECTION 413.122	413.122 Payment for hospital outpatient radiology services and other diagnostic procedures.
42:2.0.1.2.14.6.61.24	SECTION 413.123	413.123 Payment for screening mammography performed by hospitals on an outpatient basis.
42:2.0.1.2.14.6.61.25	SECTION 413.124	413.124 Reduction to hospital outpatient operating costs.
42:2.0.1.2.14.6.61.26	SECTION 413.125	413.125 Payment for home health agency services.
42:2.0.1.2.14.7	SUBPART G	Subpart G - Capital-Related Costs
42:2.0.1.2.14.7.61.1	SECTION 413.130	413.130 Introduction to capital-related costs.
42:2.0.1.2.14.7.61.2	SECTION 413.134	413.134 Depreciation: Allowance for depreciation based on asset costs.
42:2.0.1.2.14.7.61.3	SECTION 413.139	413.139 Depreciation: Optional allowance for depreciation based on a percentage of operating costs.
42:2.0.1.2.14.7.61.4	SECTION 413.144	413.144 Depreciation: Allowance for depreciation on fully depreciated or partially depreciated assets.
42:2.0.1.2.14.7.61.5	SECTION 413.149	413.149 Depreciation: Allowance for depreciation on assets financed with Federal or public funds.
42:2.0.1.2.14.7.61.6	SECTION 413.153	413.153 Interest expense.
42:2.0.1.2.14.7.61.7	SECTION 413.157	413.157 Return on equity capital of proprietary providers.
42:2.0.1.2.14.8	SUBPART H	Subpart H - Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs
42:2.0.1.2.14.8.61.1	SECTION 413.170	413.170 Scope.
42:2.0.1.2.14.8.61.2	SECTION 413.171	413.171 Definitions.
42:2.0.1.2.14.8.61.3	SECTION 413.172	413.172 Principles of prospective payment.
42:2.0.1.2.14.8.61.4	SECTION 413.174	413.174 Prospective rates for hospital-based and independent ESRD facilities.
42:2.0.1.2.14.8.61.5	SECTION 413.176	413.176 Amount of payments.
42:2.0.1.2.14.8.61.6	SECTION 413.177	413.177 Quality incentive program payment.
42:2.0.1.2.14.8.61.7	SECTION 413.178	413.178 ESRD quality incentive program.
42:2.0.1.2.14.8.61.8	SECTION 413.180	413.180 Procedures for requesting exceptions to payment rates.
42:2.0.1.2.14.8.61.9	SECTION 413.182	413.182 Criteria for approval of exception requests.
42:2.0.1.2.14.8.61.10	SECTION 413.184	413.184 Payment exception: Pediatric patient mix.
42:2.0.1.2.14.8.61.11	SECTION 413.186	413.186 Payment exception: Self-dialysis training costs in pediatric facilities.
42:2.0.1.2.14.8.61.12	SECTION 413.194	413.194 Appeals.
42:2.0.1.2.14.8.61.13	SECTION 413.195	413.195 Limitation on Review.
42:2.0.1.2.14.8.61.14	SECTION 413.196	413.196 Notification of changes in rate-setting methodologies and payment rates.
42:2.0.1.2.14.8.61.15	SECTION 413.198	413.198 Recordkeeping and cost reporting requirements for outpatient maintenance dialysis.
42:2.0.1.2.14.8.61.16	SECTION 413.200	413.200 Payment of independent organ procurement organizations and histocompatibility laboratories.
42:2.0.1.2.14.8.61.17	SECTION 413.202	413.202 Organ procurement organization (OPO) cost for kidneys sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
42:2.0.1.2.14.8.61.18	SECTION 413.203	413.203 Transplant center costs for organs sent to foreign countries or transplanted in patients other than Medicare beneficiaries.
42:2.0.1.2.14.8.61.19	SECTION 413.210	413.210 Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.
42:2.0.1.2.14.8.61.20	SECTION 413.215	413.215 Basis of payment.
42:2.0.1.2.14.8.61.21	SECTION 413.217	413.217 Items and services included in the ESRD prospective payment system.
42:2.0.1.2.14.8.61.22	SECTION 413.220	413.220 Methodology for calculating the per-treatment base rate under the ESRD prospective payment system effective January 1, 2011.
42:2.0.1.2.14.8.61.23	SECTION 413.230	413.230 Determining the per treatment payment amount.
42:2.0.1.2.14.8.61.24	SECTION 413.231	413.231 Adjustment for wages.
42:2.0.1.2.14.8.61.25	SECTION 413.232	413.232 Low-volume adjustment.
42:2.0.1.2.14.8.61.26	SECTION 413.233	413.233 Rural facility adjustment.
42:2.0.1.2.14.8.61.27	SECTION 413.234.	413.234. Drug designation process.
42:2.0.1.2.14.8.61.28	SECTION 413.235	413.235 Patient-level adjustments.
42:2.0.1.2.14.8.61.29	SECTION 413.236	413.236 Transitional add-on payment adjustment for new and innovative equipment and supplies.
42:2.0.1.2.14.8.61.30	SECTION 413.237	413.237 Outliers.
42:2.0.1.2.14.8.61.31	SECTION 413.239	413.239 Transition period.
42:2.0.1.2.14.8.61.32	SECTION 413.241	413.241 Pharmacy arrangements.
42:2.0.1.2.14.9	SUBPART I	Subpart I - Prospectively Determined Payment Rates for Low-Volume Skilled Nursing Facilities, for Cost Reporting Periods Beginning Prior to July 1, 1998
42:2.0.1.2.14.9.61.1	SECTION 413.300	413.300 Basis and scope.
42:2.0.1.2.14.9.61.2	SECTION 413.302	413.302 Definitions.
42:2.0.1.2.14.9.61.3	SECTION 413.304	413.304 Eligibility for prospectively determined payment rates.
42:2.0.1.2.14.9.61.4	SECTION 413.308	413.308 Rules governing election of prospectively determined payment rates.
42:2.0.1.2.14.9.61.5	SECTION 413.310	413.310 Basis of payment.
42:2.0.1.2.14.9.61.6	SECTION 413.312	413.312 Methodology for calculating rates.
42:2.0.1.2.14.9.61.7	SECTION 413.314	413.314 Determining payment amounts: Routine per diem rate.
42:2.0.1.2.14.9.61.8	SECTION 413.316	413.316 Determining payment amounts: Ancillary services.
42:2.0.1.2.14.9.61.9	SECTION 413.320	413.320 Publication of prospectively determined payment rates or amounts.
42:2.0.1.2.14.9.61.10	SECTION 413.321	413.321 Simplified cost report for SNFs.
42:2.0.1.2.14.10	SUBPART J	Subpart J - Prospective Payment for Skilled Nursing Facilities
42:2.0.1.2.14.10.61.1	SECTION 413.330	413.330 Basis and scope.
42:2.0.1.2.14.10.61.2	SECTION 413.333	413.333 Definitions.
42:2.0.1.2.14.10.61.3	SECTION 413.335	413.335 Basis of payment.
42:2.0.1.2.14.10.61.4	SECTION 413.337	413.337 Methodology for calculating the prospective payment rates.
42:2.0.1.2.14.10.61.5	SECTION 413.338	413.338 Skilled nursing facility value-based purchasing program.
42:2.0.1.2.14.10.61.6	SECTION 413.340	413.340 Transition period.
42:2.0.1.2.14.10.61.7	SECTION 413.343	413.343 Resident assessment data.
42:2.0.1.2.14.10.61.8	SECTION 413.345	413.345 Publication of Federal prospective payment rates.
42:2.0.1.2.14.10.61.9	SECTION 413.348	413.348 Limitation on review.
42:2.0.1.2.14.10.61.10	SECTION 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.
42:2.0.1.2.14.10.61.11	SECTION 413.355	413.355 Additional payment: QIO reimbursement for cost of sending records electronically or by photocopy and mailing.
42:2.0.1.2.14.10.61.12	SECTION 413.360	413.360 Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP).
42:2.0.1.2.14.11	SUBPART K	Subpart K - Payment for Acute Kidney Injury (AKI) Dialysis
42:2.0.1.2.14.11.61.1	SECTION 413.370	413.370 Scope.
42:2.0.1.2.14.11.61.2	SECTION 413.371	413.371 Definition.
42:2.0.1.2.14.11.61.3	SECTION 413.372	413.372 AKI dialysis payment rate.
42:2.0.1.2.14.11.61.4	SECTION 413.373	413.373 Other adjustments to the AKI dialysis payment rate
42:2.0.1.2.14.11.61.5	SECTION 413.374	413.374 Renal dialysis services included in the AKI dialysis payment rate
42:2.0.1.2.14.11.61.6	SECTION 413.375	413.375 Notification of changes in rate-setting methodologies and payment rates.

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