Title 42

PART 405 SUBPART I

Subpart I - Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B) Source:70 FR 11472, Mar. 8, 2005, unless otherwise noted.

42:2.0.1.2.6.9.25SUBJGRP 25
Initial Determinations
42:2.0.1.2.6.9.25.1SECTION 405.900
   405.900 Basis and scope.
42:2.0.1.2.6.9.25.2SECTION 405.902
   405.902 Definitions.
42:2.0.1.2.6.9.25.3SECTION 405.904
   405.904 Medicare initial determinations, redeterminations and appeals: General description.
42:2.0.1.2.6.9.25.4SECTION 405.906
   405.906 Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.
42:2.0.1.2.6.9.25.5SECTION 405.908
   405.908 Medicaid State agencies.
42:2.0.1.2.6.9.25.6SECTION 405.910
   405.910 Appointed representatives.
42:2.0.1.2.6.9.25.7SECTION 405.912
   405.912 Assignment of appeal rights.
42:2.0.1.2.6.9.25.8SECTION 405.920
   405.920 Initial determinations.
42:2.0.1.2.6.9.25.9SECTION 405.921
   405.921 Notice of initial determination.
42:2.0.1.2.6.9.25.10SECTION 405.922
   405.922 Time frame for processing initial determinations.
42:2.0.1.2.6.9.25.11SECTION 405.924
   405.924 Actions that are initial determinations.
42:2.0.1.2.6.9.25.12SECTION 405.925
   405.925 Decisions of utilization review committees.
42:2.0.1.2.6.9.25.13SECTION 405.926
   405.926 Actions that are not initial determinations.
42:2.0.1.2.6.9.25.14SECTION 405.927
   405.927 Initial determinations subject to the reopenings process.
42:2.0.1.2.6.9.25.15SECTION 405.928
   405.928 Effect of the initial determination.
42:2.0.1.2.6.9.26SUBJGRP 26
Redeterminations
42:2.0.1.2.6.9.26.16SECTION 405.940
   405.940 Right to a redetermination.
42:2.0.1.2.6.9.26.17SECTION 405.942
   405.942 Time frame for filing a request for a redetermination.
42:2.0.1.2.6.9.26.18SECTION 405.944
   405.944 Place and method of filing a request for a redetermination.
42:2.0.1.2.6.9.26.19SECTION 405.946
   405.946 Evidence to be submitted with the redetermination request.
42:2.0.1.2.6.9.26.20SECTION 405.947
   405.947 Notice to the beneficiary of applicable plan's request for a redetermination.
42:2.0.1.2.6.9.26.21SECTION 405.948
   405.948 Conduct of a redetermination.
42:2.0.1.2.6.9.26.22SECTION 405.950
   405.950 Time frame for making a redetermination.
42:2.0.1.2.6.9.26.23SECTION 405.952
   405.952 Withdrawal or dismissal of a request for a redetermination.
42:2.0.1.2.6.9.26.24SECTION 405.954
   405.954 Redetermination.
42:2.0.1.2.6.9.26.25SECTION 405.956
   405.956 Notice of a redetermination.
42:2.0.1.2.6.9.26.26SECTION 405.958
   405.958 Effect of a redetermination.
42:2.0.1.2.6.9.27SUBJGRP 27
Reconsideration
42:2.0.1.2.6.9.27.27SECTION 405.960
   405.960 Right to a reconsideration.
42:2.0.1.2.6.9.27.28SECTION 405.962
   405.962 Timeframe for filing a request for a reconsideration.
42:2.0.1.2.6.9.27.29SECTION 405.964
   405.964 Place and method of filing a request for a reconsideration.
42:2.0.1.2.6.9.27.30SECTION 405.966
   405.966 Evidence to be submitted with the reconsideration request.
42:2.0.1.2.6.9.27.31SECTION 405.968
   405.968 Conduct of a reconsideration.
42:2.0.1.2.6.9.27.32SECTION 405.970
   405.970 Timeframe for making a reconsideration following a contractor redetermination.
42:2.0.1.2.6.9.27.33SECTION 405.972
   405.972 Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.
42:2.0.1.2.6.9.27.34SECTION 405.974
   405.974 Reconsideration and review of a contractor's dismissal of a request for redetermination.
42:2.0.1.2.6.9.27.35SECTION 405.976
   405.976 Notice of a reconsideration.
42:2.0.1.2.6.9.27.36SECTION 405.978
   405.978 Effect of a reconsideration.
42:2.0.1.2.6.9.28SUBJGRP 28
Reopenings
42:2.0.1.2.6.9.28.37SECTION 405.980
   405.980 Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.
42:2.0.1.2.6.9.28.38SECTION 405.982
   405.982 Notice of a revised determination or decision.
42:2.0.1.2.6.9.28.39SECTION 405.984
   405.984 Effect of a revised determination or decision.
42:2.0.1.2.6.9.28.40SECTION 405.986
   405.986 Good cause for reopening.
42:2.0.1.2.6.9.29SUBJGRP 29
Expedited Access to Judicial Review
42:2.0.1.2.6.9.29.41SECTION 405.990
   405.990 Expedited access to judicial review.
42:2.0.1.2.6.9.30SUBJGRP 30
ALJ Hearings
42:2.0.1.2.6.9.30.42SECTION 405.1000
   405.1000 Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
42:2.0.1.2.6.9.30.43SECTION 405.1002
   405.1002 Right to an ALJ hearing.
42:2.0.1.2.6.9.30.44SECTION 405.1004
   405.1004 Right to a review of QIC notice of dismissal.
42:2.0.1.2.6.9.30.45SECTION 405.1006
   405.1006 Amount in controversy required for an ALJ hearing and judicial review.
42:2.0.1.2.6.9.30.46SECTION 405.1008
   405.1008 Parties to the proceedings on a request for an ALJ hearing.
42:2.0.1.2.6.9.30.47SECTION 405.1010
   405.1010 When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.
42:2.0.1.2.6.9.30.48SECTION 405.1012
   405.1012 When CMS or its contractors may be a party to a hearing.
42:2.0.1.2.6.9.30.49SECTION 405.1014
   405.1014 Request for an ALJ hearing or a review of a QIC dismissal.
42:2.0.1.2.6.9.30.50SECTION 405.1016
   405.1016 Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.
42:2.0.1.2.6.9.30.51SECTION 405.1018
   405.1018 Submitting evidence.
42:2.0.1.2.6.9.30.52SECTION 405.1020
   405.1020 Time and place for a hearing before an ALJ.
42:2.0.1.2.6.9.30.53SECTION 405.1022
   405.1022 Notice of a hearing before an ALJ.
42:2.0.1.2.6.9.30.54SECTION 405.1024
   405.1024 Objections to the issues.
42:2.0.1.2.6.9.30.55SECTION 405.1026
   405.1026 Disqualification of the ALJ or attorney adjudicator.
42:2.0.1.2.6.9.30.56SECTION 405.1028
   405.1028 Review of evidence submitted by parties.
42:2.0.1.2.6.9.30.57SECTION 405.1030
   405.1030 ALJ hearing procedures.
42:2.0.1.2.6.9.30.58SECTION 405.1032
   405.1032 Issues before an ALJ or attorney adjudicator.
42:2.0.1.2.6.9.30.59SECTION 405.1034
   405.1034 Requesting information from the QIC.
42:2.0.1.2.6.9.30.60SECTION 405.1036
   405.1036 Description of an ALJ hearing process.
42:2.0.1.2.6.9.30.61SECTION 405.1037
   405.1037 Discovery.
42:2.0.1.2.6.9.30.62SECTION 405.1038
   405.1038 Deciding a case without a hearing before an ALJ.
42:2.0.1.2.6.9.30.63SECTION 405.1040
   405.1040 Prehearing and posthearing conferences.
42:2.0.1.2.6.9.30.64SECTION 405.1042
   405.1042 The administrative record.
42:2.0.1.2.6.9.30.65SECTION 405.1044
   405.1044 Consolidated proceedings.
42:2.0.1.2.6.9.30.66SECTION 405.1046
   405.1046 Notice of an ALJ or attorney adjudicator decision.
42:2.0.1.2.6.9.30.67SECTION 405.1048
   405.1048 The effect of an ALJ's or attorney adjudicator's decision.
42:2.0.1.2.6.9.30.68SECTION 405.1050
   405.1050 Removal of a hearing request from OMHA to the Council.
42:2.0.1.2.6.9.30.69SECTION 405.1052
   405.1052 Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.
42:2.0.1.2.6.9.30.70SECTION 405.1054
   405.1054 Effect of dismissal of a request for a hearing or request for review of QIC dismissal.
42:2.0.1.2.6.9.30.71SECTION 405.1056
   405.1056 Remands of requests for hearing and requests for review.
42:2.0.1.2.6.9.30.72SECTION 405.1058
   405.1058 Effect of a remand.
42:2.0.1.2.6.9.31SUBJGRP 31
Applicability of Medicare Coverage Policies
42:2.0.1.2.6.9.31.73SECTION 405.1060
   405.1060 Applicability of national coverage determinations (NCDs).
42:2.0.1.2.6.9.31.74SECTION 405.1062
   405.1062 Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.
42:2.0.1.2.6.9.31.75SECTION 405.1063
   405.1063 Applicability of laws, regulations, CMS Rulings, and precedential decisions.
42:2.0.1.2.6.9.32SUBJGRP 32
Medicare Appeals Council Review
42:2.0.1.2.6.9.32.76SECTION 405.1100
   405.1100 Medicare Appeals Council review: General.
42:2.0.1.2.6.9.32.77SECTION 405.1102
   405.1102 Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
42:2.0.1.2.6.9.32.78SECTION 405.1106
   405.1106 Where a request for review or escalation may be filed.
42:2.0.1.2.6.9.32.79SECTION 405.1108
   405.1108 Council actions when request for review or escalation is filed.
42:2.0.1.2.6.9.32.80SECTION 405.1110
   405.1110 Council reviews on its own motion.
42:2.0.1.2.6.9.32.81SECTION 405.1112
   405.1112 Content of request for review.
42:2.0.1.2.6.9.32.82SECTION 405.1114
   405.1114 Dismissal of request for review.
42:2.0.1.2.6.9.32.83SECTION 405.1116
   405.1116 Effect of dismissal of request for Council review or request for hearing.
42:2.0.1.2.6.9.32.84SECTION 405.1118
   405.1118 Obtaining evidence from the Council.
42:2.0.1.2.6.9.32.85SECTION 405.1120
   405.1120 Filing briefs with the Council.
42:2.0.1.2.6.9.32.86SECTION 405.1122
   405.1122 What evidence may be submitted to the Council.
42:2.0.1.2.6.9.32.87SECTION 405.1124
   405.1124 Oral argument.
42:2.0.1.2.6.9.32.88SECTION 405.1126
   405.1126 Case remanded by the Council.
42:2.0.1.2.6.9.32.89SECTION 405.1128
   405.1128 Action of the Council.
42:2.0.1.2.6.9.32.90SECTION 405.1130
   405.1130 Effect of the Council's decision.
42:2.0.1.2.6.9.32.91SECTION 405.1132
   405.1132 Request for escalation to Federal court.
42:2.0.1.2.6.9.32.92SECTION 405.1134
   405.1134 Extension of time to file action in Federal district court.
42:2.0.1.2.6.9.32.93SECTION 405.1136
   405.1136 Judicial review.
42:2.0.1.2.6.9.32.94SECTION 405.1138
   405.1138 Case remanded by a Federal district court.
42:2.0.1.2.6.9.32.95SECTION 405.1140
   405.1140 Council review of ALJ decision in a case remanded by a Federal district court.