Title 42

Volume 3 CHAPTER IV SUBCHAP B

Subchapter B - Medicare Program (continued)

42:3.0.1.1.1	PART 414	PART 414 - PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
42:3.0.1.1.1.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.1.1.3.1	SECTION 414.1	414.1 Basis and scope.
42:3.0.1.1.1.1.3.2	SECTION 414.2	414.2 Definitions.
42:3.0.1.1.1.1.3.3	SECTION 414.4	414.4 Fee schedule areas.
42:3.0.1.1.1.1.3.4	SECTION 414.5	414.5 Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary.
42:3.0.1.1.1.2	SUBPART B	Subpart B - Physicians and Other Practitioners
42:3.0.1.1.1.2.3.1	SECTION 414.20	414.20 Formula for computing fee schedule amounts.
42:3.0.1.1.1.2.3.2	SECTION 414.21	414.21 Medicare payment basis.
42:3.0.1.1.1.2.3.3	SECTION 414.22	414.22 Relative value units (RVUs).
42:3.0.1.1.1.2.3.4	SECTION 414.24	414.24 Publication of RVUs and direct PE inputs.
42:3.0.1.1.1.2.3.5	SECTION 414.26	414.26 Determining the GAF.
42:3.0.1.1.1.2.3.6	SECTION 414.28	414.28 Conversion factors.
42:3.0.1.1.1.2.3.7	SECTION 414.30	414.30 Conversion factor update.
42:3.0.1.1.1.2.3.8	SECTION 414.34	414.34 Payment for services and supplies incident to a physician's service.
42:3.0.1.1.1.2.3.9	SECTION 414.36	414.36 Payment for drugs incident to a physician's service.
42:3.0.1.1.1.2.3.10	SECTION 414.39	414.39 Special rules for payment of care plan oversight.
42:3.0.1.1.1.2.3.11	SECTION 414.40	414.40 Coding and ancillary policies.
42:3.0.1.1.1.2.3.12	SECTION 414.42	414.42 Adjustment for first 4 years of practice.
42:3.0.1.1.1.2.3.13	SECTION 414.44	414.44 Transition rules.
42:3.0.1.1.1.2.3.14	SECTION 414.46	414.46 Additional rules for payment of anesthesia services.
42:3.0.1.1.1.2.3.15	SECTION 414.48	414.48 Limits on actual charges of nonparticipating suppliers.
42:3.0.1.1.1.2.3.16	SECTION 414.50	414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.
42:3.0.1.1.1.2.3.17	SECTION 414.52	414.52 Payment for physician assistants' services.
42:3.0.1.1.1.2.3.18	SECTION 414.54	414.54 Payment for certified nurse-midwives' services.
42:3.0.1.1.1.2.3.19	SECTION 414.56	414.56 Payment for nurse practitioners' and clinical nurse specialists' services.
42:3.0.1.1.1.2.3.20	SECTION 414.58	414.58 Payment of charges for physician services to patients in providers.
42:3.0.1.1.1.2.3.21	SECTION 414.60	414.60 Payment for the services of CRNAs.
42:3.0.1.1.1.2.3.22	SECTION 414.61	414.61 Payment for anesthesia services furnished by a teaching CRNA.
42:3.0.1.1.1.2.3.23	SECTION 414.62	414.62 Fee schedule for clinical psychologist services.
42:3.0.1.1.1.2.3.24	SECTION 414.63	414.63 Payment for outpatient diabetes self-management training.
42:3.0.1.1.1.2.3.25	SECTION 414.64	414.64 Payment for medical nutrition therapy.
42:3.0.1.1.1.2.3.26	SECTION 414.65	414.65 Payment for telehealth services.
42:3.0.1.1.1.2.3.27	SECTION 414.66	414.66 Incentive payments for physician scarcity areas.
42:3.0.1.1.1.2.3.28	SECTION 414.67	414.67 Incentive payments for services furnished in Health Professional Shortage Areas.
42:3.0.1.1.1.2.3.29	SECTION 414.68	414.68 Imaging accreditation.
42:3.0.1.1.1.2.3.30	SECTION 414.80	414.80 Incentive payment for primary care services.
42:3.0.1.1.1.2.3.31	SECTION 414.84	414.84 Payment for MDPP services.
42:3.0.1.1.1.2.3.32	SECTION 414.90	414.90 Physician Quality Reporting System (PQRS).
42:3.0.1.1.1.2.3.33	SECTION 414.92	414.92 Electronic Prescribing Incentive Program.
42:3.0.1.1.1.2.3.34	SECTION 414.94	414.94 Appropriate use criteria for advanced diagnostic imaging services.
42:3.0.1.1.1.3	SUBPART C	Subpart C - Fee Schedules for Parenteral and Enteral Nutrition (PEN) Nutrients, Equipment and Supplies, Splints, Casts, and Certain Intraocular Lenses (IOLs)
42:3.0.1.1.1.3.3.1	SECTION 414.100	414.100 Purpose.
42:3.0.1.1.1.3.3.2	SECTION 414.102	414.102 General payment rules.
42:3.0.1.1.1.3.3.3	SECTION 414.104	414.104 PEN Items and Services.
42:3.0.1.1.1.3.3.4	SECTION 414.105	414.105 Application of competitive bidding information.
42:3.0.1.1.1.3.3.5	SECTION 414.106	414.106 Splints and casts.
42:3.0.1.1.1.3.3.6	SECTION 414.108	414.108 IOLs inserted in a physician's office.
42:3.0.1.1.1.3.3.7	SECTION 414.110	414.110 Continuity of pricing when HCPCS codes are divided or combined.
42:3.0.1.1.1.3.3.8	SECTION 414.112	414.112 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
42:3.0.1.1.1.4	SUBPART D	Subpart D - Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
42:3.0.1.1.1.4.3.1	SECTION 414.200	414.200 Purpose.
42:3.0.1.1.1.4.3.2	SECTION 414.202	414.202 Definitions.
42:3.0.1.1.1.4.3.3	SECTION 414.210	414.210 General payment rules.
42:3.0.1.1.1.4.3.4	SECTION 414.220	414.220 Inexpensive or routinely purchased items.
42:3.0.1.1.1.4.3.5	SECTION 414.222	414.222 Items requiring frequent and substantial servicing.
42:3.0.1.1.1.4.3.6	SECTION 414.224	414.224 Customized items.
42:3.0.1.1.1.4.3.7	SECTION 414.226	414.226 Oxygen and oxygen equipment.
42:3.0.1.1.1.4.3.8	SECTION 414.228	414.228 Prosthetic and orthotic devices.
42:3.0.1.1.1.4.3.9	SECTION 414.229	414.229 Other durable medical equipment - capped rental items.
42:3.0.1.1.1.4.3.10	SECTION 414.230	414.230 Determining a period of continuous use.
42:3.0.1.1.1.4.3.11	SECTION 414.232	414.232 Special payment rules for transcutaneous electrical nerve stimulators (TENS).
42:3.0.1.1.1.4.3.12	SECTION 414.234	414.234 Prior authorization for items frequently subject to unnecessary utilization.
42:3.0.1.1.1.4.3.13	SECTION 414.236	414.236 Continuity of pricing when HCPCS codes are divided or combined.
42:3.0.1.1.1.4.3.14	SECTION 414.238	414.238 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
42:3.0.1.1.1.5	SUBPART E	Subpart E - Determination of Reasonable Charges Under the ESRD Program
42:3.0.1.1.1.5.3.1	SECTION 414.300	414.300 Scope of subpart.
42:3.0.1.1.1.5.3.2	SECTION 414.310	414.310 Determination of reasonable charges for physician services furnished to renal dialysis patients.
42:3.0.1.1.1.5.3.3	SECTION 414.313	414.313 Initial method of payment.
42:3.0.1.1.1.5.3.4	SECTION 414.314	414.314 Monthly capitation payment method.
42:3.0.1.1.1.5.3.5	SECTION 414.316	414.316 Payment for physician services to patients in training for self-dialysis and home dialysis.
42:3.0.1.1.1.5.3.6	SECTION 414.320	414.320 Determination of reasonable charges for physician renal transplantation services.
42:3.0.1.1.1.5.3.7	SECTION 414.330	414.330 Payment for home dialysis equipment, supplies, and support services.
42:3.0.1.1.1.5.3.8	SECTION 414.335	414.335 Payment for EPO furnished to a home dialysis patient for use in the home.
42:3.0.1.1.1.6	SUBPART F	Subpart F - Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
42:3.0.1.1.1.6.3.1	SECTION 414.400	414.400 Purpose and basis.
42:3.0.1.1.1.6.3.2	SECTION 414.402	414.402 Definitions.
42:3.0.1.1.1.6.3.3	SECTION 414.404	414.404 Scope and applicability.
42:3.0.1.1.1.6.3.4	SECTION 414.406	414.406 Implementation of programs.
42:3.0.1.1.1.6.3.5	SECTION 414.408	414.408 Payment rules.
42:3.0.1.1.1.6.3.6	SECTION 414.409	414.409 Special payment rules.
42:3.0.1.1.1.6.3.7	SECTION 414.410	414.410 Phased-in implementation of competitive bidding programs.
42:3.0.1.1.1.6.3.8	SECTION 414.411	414.411 Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011.
42:3.0.1.1.1.6.3.9	SECTION 414.412	414.412 Submission of bids under a competitive bidding program.
42:3.0.1.1.1.6.3.10	SECTION 414.414	414.414 Conditions for awarding contracts.
42:3.0.1.1.1.6.3.11	SECTION 414.416	414.416 Determination of competitive bidding payment amounts.
42:3.0.1.1.1.6.3.12	SECTION 414.418	414.418 Opportunity for networks.
42:3.0.1.1.1.6.3.13	SECTION 414.420	414.420 Physician or treating practitioner authorization and consideration of clinical efficiency and value of items.
42:3.0.1.1.1.6.3.14	SECTION 414.422	414.422 Terms of contracts.
42:3.0.1.1.1.6.3.15	SECTION 414.423	414.423 Appeals process for breach of a DMEPOS competitive bidding program contract actions.
42:3.0.1.1.1.6.3.16	SECTION 414.424	414.424 Administrative or judicial review.
42:3.0.1.1.1.6.3.17	SECTION 414.425	414.425 Claims for damages.
42:3.0.1.1.1.6.3.18	SECTION 414.426	414.426 Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.
42:3.0.1.1.1.7	SUBPART G	Subpart G - Payment for Clinical Diagnostic Laboratory Tests
42:3.0.1.1.1.7.3.1	SECTION 414.500	414.500 Basis and scope.
42:3.0.1.1.1.7.3.2	SECTION 414.502	414.502 Definitions.
42:3.0.1.1.1.7.3.3	SECTION 414.504	414.504 Data reporting requirements.
42:3.0.1.1.1.7.3.4	SECTION 414.506	414.506 Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.5	SECTION 414.507	414.507 Payment for clinical diagnostic laboratory tests.
42:3.0.1.1.1.7.3.6	SECTION 414.508	414.508 Payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.7	SECTION 414.509	414.509 Reconsideration of basis for and amount of payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.8	SECTION 414.510	414.510 Laboratory date of service for clinical laboratory and pathology specimens.
42:3.0.1.1.1.7.3.9	SECTION 414.522	414.522 Payment for new advanced diagnostic laboratory tests.
42:3.0.1.1.1.8	SUBPART H	Subpart H - Fee Schedule for Ambulance Services
42:3.0.1.1.1.8.3.1	SECTION 414.601	414.601 Purpose.
42:3.0.1.1.1.8.3.2	SECTION 414.605	414.605 Definitions.
42:3.0.1.1.1.8.3.3	SECTION 414.610	414.610 Basis of payment.
42:3.0.1.1.1.8.3.4	SECTION 414.615	414.615 Transition to the ambulance fee schedule.
42:3.0.1.1.1.8.3.5	SECTION 414.617	414.617 Transition from regional to national ambulance fee schedule.
42:3.0.1.1.1.8.3.6	SECTION 414.620	414.620 Publication of the ambulance fee schedule.
42:3.0.1.1.1.8.3.7	SECTION 414.625	414.625 Limitation on review.
42:3.0.1.1.1.8.3.8	SECTION 414.626	414.626 Data reporting by ground ambulance organizations.
42:3.0.1.1.1.9	SUBPART I	Subpart I - Payment for Drugs and Biologicals
42:3.0.1.1.1.9.3.1	SECTION 414.701	414.701 Purpose.
42:3.0.1.1.1.9.3.2	SECTION 414.704	414.704 Definitions.
42:3.0.1.1.1.9.3.3	SECTION 414.707	414.707 Basis of payment.
42:3.0.1.1.1.10	SUBPART J	Subpart J - Submission of Manufacturer's Average Sales Price Data
42:3.0.1.1.1.10.3.1	SECTION 414.800	414.800 Purpose.
42:3.0.1.1.1.10.3.2	SECTION 414.802	414.802 Definitions.
42:3.0.1.1.1.10.3.3	SECTION 414.804	414.804 Basis of payment.
42:3.0.1.1.1.10.3.4	SECTION 414.806	414.806 Penalties associated with the failure to submit timely and accurate ASP data.
42:3.0.1.1.1.11	SUBPART K	Subpart K - Payment for Drugs and Biologicals Under Part B
42:3.0.1.1.1.11.3.1	SECTION 414.900	414.900 Basis and scope.
42:3.0.1.1.1.11.3.2	SECTION 414.902	414.902 Definitions.
42:3.0.1.1.1.11.3.3	SECTION 414.904	414.904 Average sales price as the basis for payment.
42:3.0.1.1.1.11.3.4	SECTION 414.906	414.906 Competitive acquisition program as the basis for payment.
42:3.0.1.1.1.11.3.5	SECTION 414.908	414.908 Competitive acquisition program.
42:3.0.1.1.1.11.3.6	SECTION 414.910	414.910 Bidding process.
42:3.0.1.1.1.11.3.7	SECTION 414.912	414.912 Conflicts of interest
42:3.0.1.1.1.11.3.8	SECTION 414.914	414.914 Terms of contract.
42:3.0.1.1.1.11.3.9	SECTION 414.916	414.916 Dispute resolution for vendors and beneficiaries.
42:3.0.1.1.1.11.3.10	SECTION 414.917	414.917 Dispute resolution and process for suspension or termination of approved CAP contract and termination of physician participation under exigent circumstances.
42:3.0.1.1.1.11.3.11	SECTION 414.918	414.918 Assignment.
42:3.0.1.1.1.11.3.12	SECTION 414.920	414.920 Judicial review.
42:3.0.1.1.1.11.3.13	SECTION 414.930	414.930 Compendia for determination of medically-accepted indications for off-label uses of drugs and biologicals in an anti-cancer chemotherapeutic regimen.
42:3.0.1.1.1.12	SUBPART L	Subpart L - Supplying and Dispensing Fees
42:3.0.1.1.1.12.3.1	SECTION 414.1000	414.1000 Purpose.
42:3.0.1.1.1.12.3.2	SECTION 414.1001	414.1001 Basis of payment.
42:3.0.1.1.1.13	SUBPART M	Subpart M - Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) Services
42:3.0.1.1.1.13.3.1	SECTION 414.1100	414.1100 Basis and scope.
42:3.0.1.1.1.13.3.2	SECTION 414.1105	414.1105 Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.
42:3.0.1.1.1.14	SUBPART N	Subpart N - Value-Based Payment Modifier Under the Physician Fee Schedule
42:3.0.1.1.1.14.3.1	SECTION 414.1200	414.1200 Basis and scope.
42:3.0.1.1.1.14.3.2	SECTION 414.1205	414.1205 Definitions.
42:3.0.1.1.1.14.3.3	SECTION 414.1210	414.1210 Application of the value-based payment modifier.
42:3.0.1.1.1.14.3.4	SECTION 414.1215	414.1215 Performance and payment adjustment periods for the value-based payment modifier.
42:3.0.1.1.1.14.3.5	SECTION 414.1220	414.1220 Reporting mechanisms for the value-based payment modifier.
42:3.0.1.1.1.14.3.6	SECTION 414.1225	414.1225 Alignment of Physician Quality Reporting System quality measures and quality measures for the value-based payment modifier.
42:3.0.1.1.1.14.3.7	SECTION 414.1230	414.1230 Additional measures for groups and solo practitioners.
42:3.0.1.1.1.14.3.8	SECTION 414.1235	414.1235 Cost measures.
42:3.0.1.1.1.14.3.9	SECTION 414.1240	414.1240 Attribution for quality of care and cost measures.
42:3.0.1.1.1.14.3.10	SECTION 414.1245	414.1245 Scoring methods for the value-based payment modifier using the quality-tiering approach.
42:3.0.1.1.1.14.3.11	SECTION 414.1250	414.1250 Benchmarks for quality of care measures.
42:3.0.1.1.1.14.3.12	SECTION 414.1255	414.1255 Benchmarks for cost measures.
42:3.0.1.1.1.14.3.13	SECTION 414.1260	414.1260 Composite scores.
42:3.0.1.1.1.14.3.14	SECTION 414.1265	414.1265 Reliability of measures.
42:3.0.1.1.1.14.3.15	SECTION 414.1270	414.1270 Determination and calculation of Value-Based Payment Modifier adjustments.
42:3.0.1.1.1.14.3.16	SECTION 414.1275	414.1275 Value-based payment modifier quality-tiering scoring methodology.
42:3.0.1.1.1.14.3.17	SECTION 414.1280	414.1280 Limitation on review.
42:3.0.1.1.1.14.3.18	SECTION 414.1285	414.1285 Informal inquiry process.
42:3.0.1.1.1.15	SUBPART O	Subpart O - Merit-Based Incentive Payment System and Alternative Payment Model Incentive
42:3.0.1.1.1.15.3.1	SECTION 414.1300	414.1300 Basis and scope.
42:3.0.1.1.1.15.3.2	SECTION 414.1305	414.1305 Definitions.
42:3.0.1.1.1.15.3.3	SECTION 414.1310	414.1310 Applicability.
42:3.0.1.1.1.15.3.4	SECTION 414.1315	414.1315 Virtual groups.
42:3.0.1.1.1.15.3.5	SECTION 414.1317	414.1317 APM Entity groups.
42:3.0.1.1.1.15.3.6	SECTION 414.1320	414.1320 MIPS performance period.
42:3.0.1.1.1.15.3.7	SECTION 414.1325	414.1325 Data submission requirements.
42:3.0.1.1.1.15.3.8	SECTION 414.1330	414.1330 Quality performance category.
42:3.0.1.1.1.15.3.9	SECTION 414.1335	414.1335 Data submission criteria for the quality performance category.
42:3.0.1.1.1.15.3.10	SECTION 414.1340	414.1340 Data completeness criteria for the quality performance category.
42:3.0.1.1.1.15.3.11	SECTION 414.1350	414.1350 Cost performance category.
42:3.0.1.1.1.15.3.12	SECTION 414.1355	414.1355 Improvement activities performance category.
42:3.0.1.1.1.15.3.13	SECTION 414.1360	414.1360 Data submission criteria for the improvement activities performance category.
42:3.0.1.1.1.15.3.14	SECTION 414.1367	414.1367 APM performance pathway.
42:3.0.1.1.1.15.3.15	SECTION 414.1370	414.1370 APM scoring standard under MIPS.
42:3.0.1.1.1.15.3.16	SECTION 414.1375	414.1375 Promoting Interoperability (PI) performance category.
42:3.0.1.1.1.15.3.17	SECTION 414.1380	414.1380 Scoring.
42:3.0.1.1.1.15.3.18	SECTION 414.1385	414.1385 Targeted review and review limitations.
42:3.0.1.1.1.15.3.19	SECTION 414.1390	414.1390 Data validation and auditing.
42:3.0.1.1.1.15.3.20	SECTION 414.1395	414.1395 Public reporting.
42:3.0.1.1.1.15.3.21	SECTION 414.1400	414.1400 Third party intermediaries.
42:3.0.1.1.1.15.3.22	SECTION 414.1405	414.1405 Payment.
42:3.0.1.1.1.15.3.23	SECTION 414.1410	414.1410 Advanced APM determination.
42:3.0.1.1.1.15.3.24	SECTION 414.1415	414.1415 Advanced APM criteria.
42:3.0.1.1.1.15.3.25	SECTION 414.1420	414.1420 Other payer advanced APM criteria.
42:3.0.1.1.1.15.3.26	SECTION 414.1425	414.1425 Qualifying APM participant determination: In general.
42:3.0.1.1.1.15.3.27	SECTION 414.1430	414.1430 Qualifying APM participant determination: QP and partial QP thresholds.
42:3.0.1.1.1.15.3.28	SECTION 414.1435	414.1435 Qualifying APM participant determination: Medicare option.
42:3.0.1.1.1.15.3.29	SECTION 414.1440	414.1440 Qualifying APM participant determination: All-payer combination option.
42:3.0.1.1.1.15.3.30	SECTION 414.1445	414.1445 Determination of other payer advanced APMs.
42:3.0.1.1.1.15.3.31	SECTION 414.1450	414.1450 APM incentive payment.
42:3.0.1.1.1.15.3.32	SECTION 414.1455	414.1455 Limitation on review.
42:3.0.1.1.1.15.3.33	SECTION 414.1460	414.1460 Monitoring and program integrity.
42:3.0.1.1.1.15.3.34	SECTION 414.1465	414.1465 Physician-focused payment models.
42:3.0.1.1.1.16	SUBPART P	Subpart P - Home Infusion Therapy Services Payment
42:3.0.1.1.1.16.3	SUBJGRP 3	Conditions for Payment
42:3.0.1.1.1.16.3.1	SECTION 414.1500	414.1500 Basis, purpose, and scope.
42:3.0.1.1.1.16.3.2	SECTION 414.1505	414.1505 Requirement for payment.
42:3.0.1.1.1.16.3.3	SECTION 414.1510	414.1510 Beneficiary qualifications for coverage of services.
42:3.0.1.1.1.16.3.4	SECTION 414.1515	414.1515 Plan of care requirements.
42:3.0.1.1.1.16.4	SUBJGRP 4	Payment System
42:3.0.1.1.1.16.4.5	SECTION 414.1550	414.1550 Basis of payment.
42:3.0.1.1.2	PART 415	PART 415 - SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS
42:3.0.1.1.2.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.2.1.5.1	SECTION 415.1	415.1 Basis and scope.
42:3.0.1.1.2.2	SUBPART B	Subpart B - Fiscal Intermediary Payments to Providers for Physician Services
42:3.0.1.1.2.2.5.1	SECTION 415.50	415.50 Scope.
42:3.0.1.1.2.2.5.2	SECTION 415.55	415.55 General payment rules.
42:3.0.1.1.2.2.5.3	SECTION 415.60	415.60 Allocation of physician compensation costs.
42:3.0.1.1.2.2.5.4	SECTION 415.70	415.70 Limits on compensation for physician services in providers.
42:3.0.1.1.2.3	SUBPART C	Subpart C - Part B Carrier Payments for Physician Services to Beneficiaries in Providers
42:3.0.1.1.2.3.5.1	SECTION 415.100	415.100 Scope.
42:3.0.1.1.2.3.5.2	SECTION 415.102	415.102 Conditions for fee schedule payment for physician services to beneficiaries in providers.
42:3.0.1.1.2.3.5.3	SECTION 415.105	415.105 Amounts of payment for physician services to beneficiaries in providers.
42:3.0.1.1.2.3.5.4	SECTION 415.110	415.110 Conditions for payment: Medically directed anesthesia services.
42:3.0.1.1.2.3.5.5	SECTION 415.120	415.120 Conditions for payment: Radiology services.
42:3.0.1.1.2.3.5.6	SECTION 415.130	415.130 Conditions for payment: Physician pathology services.
42:3.0.1.1.2.4	SUBPART D	Subpart D - Physician Services in Teaching Settings
42:3.0.1.1.2.4.5.1	SECTION 415.150	415.150 Scope.
42:3.0.1.1.2.4.5.2	SECTION 415.152	415.152 Definitions.
42:3.0.1.1.2.4.5.3	SECTION 415.160	415.160 Election of reasonable cost payment for direct medical and surgical services of physicians in teaching hospitals: General provisions.
42:3.0.1.1.2.4.5.4	SECTION 415.162	415.162 Determining payment for physician services furnished to beneficiaries in teaching hospitals.
42:3.0.1.1.2.4.5.5	SECTION 415.164	415.164 Payment to a fund.
42:3.0.1.1.2.4.5.6	SECTION 415.170	415.170 Conditions for payment on a fee schedule basis for physician services in a teaching setting.
42:3.0.1.1.2.4.5.7	SECTION 415.172	415.172 Physician fee schedule payment for services of teaching physicians.
42:3.0.1.1.2.4.5.8	SECTION 415.174	415.174 Exception: Evaluation and management services furnished in certain centers.
42:3.0.1.1.2.4.5.9	SECTION 415.176	415.176 Renal dialysis services.
42:3.0.1.1.2.4.5.10	SECTION 415.178	415.178 Anesthesia services.
42:3.0.1.1.2.4.5.11	SECTION 415.180	415.180 Teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic tests.
42:3.0.1.1.2.4.5.12	SECTION 415.184	415.184 Psychiatric services.
42:3.0.1.1.2.4.5.13	SECTION 415.190	415.190 Conditions of payment: Assistants at surgery in teaching hospitals.
42:3.0.1.1.2.5	SUBPART E	Subpart E - Services of Residents
42:3.0.1.1.2.5.5.1	SECTION 415.200	415.200 Services of residents in approved GME programs.
42:3.0.1.1.2.5.5.2	SECTION 415.202	415.202 Services of residents not in approved GME programs.
42:3.0.1.1.2.5.5.3	SECTION 415.204	415.204 Services of residents in skilled nursing facilities and home health agencies.
42:3.0.1.1.2.5.5.4	SECTION 415.206	415.206 Services of residents in nonprovider settings.
42:3.0.1.1.2.5.5.5	SECTION 415.208	415.208 Services of moonlighting residents.
42:3.0.1.1.3	PART 416	PART 416 - AMBULATORY SURGICAL SERVICES
42:3.0.1.1.3.1	SUBPART A	Subpart A - General Provisions and Definitions
42:3.0.1.1.3.1.5.1	SECTION 416.1	416.1 Basis and scope.
42:3.0.1.1.3.1.5.2	SECTION 416.2	416.2 Definitions.
42:3.0.1.1.3.2	SUBPART B	Subpart B - General Conditions and Requirements
42:3.0.1.1.3.2.5.1	SECTION 416.25	416.25 Basic requirements.
42:3.0.1.1.3.2.5.2	SECTION 416.26	416.26 Qualifying for an agreement.
42:3.0.1.1.3.2.5.3	SECTION 416.30	416.30 Terms of agreement with CMS.
42:3.0.1.1.3.2.5.4	SECTION 416.35	416.35 Termination of agreement.
42:3.0.1.1.3.3	SUBPART C	Subpart C - Specific Conditions for Coverage
42:3.0.1.1.3.3.5.1	SECTION 416.40	416.40 Condition for coverage - Compliance with State licensure law.
42:3.0.1.1.3.3.5.2	SECTION 416.41	416.41 Condition for coverage - Governing body and management.
42:3.0.1.1.3.3.5.3	SECTION 416.42	416.42 Condition for coverage - Surgical services.
42:3.0.1.1.3.3.5.4	SECTION 416.43	416.43 Conditions for coverage - Quality assessment and performance improvement.
42:3.0.1.1.3.3.5.5	SECTION 416.44	416.44 Condition for coverage - Environment.
42:3.0.1.1.3.3.5.6	SECTION 416.45	416.45 Condition for coverage - Medical staff.
42:3.0.1.1.3.3.5.7	SECTION 416.46	416.46 Condition for coverage - Nursing services.
42:3.0.1.1.3.3.5.8	SECTION 416.47	416.47 Condition for coverage - Medical records.
42:3.0.1.1.3.3.5.9	SECTION 416.48	416.48 Condition for coverage - Pharmaceutical services.
42:3.0.1.1.3.3.5.10	SECTION 416.49	416.49 Condition for coverage - Laboratory and radiologic services.
42:3.0.1.1.3.3.5.11	SECTION 416.50	416.50 Condition for coverage - Patient rights.
42:3.0.1.1.3.3.5.12	SECTION 416.51	416.51 Conditions for coverage - Infection control.
42:3.0.1.1.3.3.5.13	SECTION 416.52	416.52 Conditions for coverage - Patient admission, assessment and discharge.
42:3.0.1.1.3.3.5.14	SECTION 416.54	416.54 Condition for coverage - Emergency preparedness.
42:3.0.1.1.3.4	SUBPART D	Subpart D - Scope of Benefits for Services Furnished Before January 1, 2008
42:3.0.1.1.3.4.5.1	SECTION 416.60	416.60 General rules.
42:3.0.1.1.3.4.5.2	SECTION 416.61	416.61 Scope of facility services.
42:3.0.1.1.3.4.5.3	SECTION 416.65	416.65 Covered surgical procedures.
42:3.0.1.1.3.4.5.4	SECTION 416.75	416.75 Performance of listed surgical procedures on an inpatient hospital basis.
42:3.0.1.1.3.4.5.5	SECTION 416.76	416.76 Applicability.
42:3.0.1.1.3.5	SUBPART E	Subpart E - Prospective Payment System for Facility Services Furnished Before January 1, 2008
42:3.0.1.1.3.5.5.1	SECTION 416.120	416.120 Basis for payment.
42:3.0.1.1.3.5.5.2	SECTION 416.121	416.121 Applicability.
42:3.0.1.1.3.5.5.3	SECTION 416.125	416.125 ASC facility services payment rate.
42:3.0.1.1.3.5.5.4	SECTION 416.130	416.130 Publication of revised payment methodologies.
42:3.0.1.1.3.5.5.5	SECTION 416.140	416.140 Surveys.
42:3.0.1.1.3.6	SUBPART F	Subpart F - Coverage, Scope of ASC Services, and Prospective Payment System for ASC Services Furnished on or After January 1, 2008
42:3.0.1.1.3.6.5.1	SECTION 416.160	416.160 Basis and scope.
42:3.0.1.1.3.6.5.2	SECTION 416.161	416.161 Applicability of this subpart.
42:3.0.1.1.3.6.5.3	SECTION 416.163	416.163 General rules.
42:3.0.1.1.3.6.5.4	SECTION 416.164	416.164 Scope of ASC services.
42:3.0.1.1.3.6.5.5	SECTION 416.166	416.166 Covered surgical procedures.
42:3.0.1.1.3.6.5.6	SECTION 416.167	416.167 Basis of payment.
42:3.0.1.1.3.6.5.7	SECTION 416.171	416.171 Determination of payment rates for ASC services.
42:3.0.1.1.3.6.5.8	SECTION 416.172	416.172 Adjustments to national payment rates.
42:3.0.1.1.3.6.5.9	SECTION 416.173	416.173 Publication of revised payment methodologies and payment rates.
42:3.0.1.1.3.6.5.10	SECTION 416.178	416.178 Limitations on administrative and judicial review.
42:3.0.1.1.3.6.5.11	SECTION 416.179	416.179 Payment and coinsurance reduction for devices replaced without cost or when full or partial credit is received.
42:3.0.1.1.3.7	SUBPART G	Subpart G - Adjustment in Payment Amounts for New Technology Intraocular Lenses Furnished by Ambulatory Service Centers
42:3.0.1.1.3.7.5.1	SECTION 416.180	416.180 Basis and scope.
42:3.0.1.1.3.7.5.2	SECTION 416.185	416.185 Process for establishing a new class of new technology IOLs.
42:3.0.1.1.3.7.5.3	SECTION 416.190	416.190 Request for review of payment amount.
42:3.0.1.1.3.7.5.4	SECTION 416.195	416.195 Determination of membership in new classes of new technology IOLs.
42:3.0.1.1.3.7.5.5	SECTION 416.200	416.200 Payment adjustment.
42:3.0.1.1.3.8	SUBPART H	Subpart H - Requirements Under the Ambulatory Surgical Center Quality Reporting (ASCQR) Program
42:3.0.1.1.3.8.5.1	SECTION 416.300	416.300 Basis and scope of subpart.
42:3.0.1.1.3.8.5.2	SECTION 416.305	416.305 Participation and withdrawal requirements under the ASCQR Program.
42:3.0.1.1.3.8.5.3	SECTION 416.310	416.310 Data collection and submission requirements under the ASCQR Program.
42:3.0.1.1.3.8.5.4	SECTION 416.315	416.315 Public reporting of data under the ASCQR Program.
42:3.0.1.1.3.8.5.5	SECTION 416.320	416.320 Retention and removal of quality measures under the ASCQR Program.
42:3.0.1.1.3.8.5.6	SECTION 416.325	416.325 Measure maintenance under the ASCQR Program.
42:3.0.1.1.3.8.5.7	SECTION 416.330	416.330 Reconsiderations under the ASCQR Program.
42:3.0.1.1.4	PART 417	PART 417 - HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
42:3.0.1.1.4.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.4.1.5.1	SECTION 417.1	417.1 Definitions.
42:3.0.1.1.4.1.5.2	SECTION 417.2	417.2 Basis and scope.
42:3.0.1.1.4.2	SUBPART B	Subpart B - Qualified Health Maintenance Organizations: Services
42:3.0.1.1.4.2.5.1	SECTION 417.101	417.101 Health benefits plan: Basic health services.
42:3.0.1.1.4.2.5.2	SECTION 417.102	417.102 Health benefits plan: Supplemental health services.
42:3.0.1.1.4.2.5.3	SECTION 417.103	417.103 Providers of basic and supplemental health services.
42:3.0.1.1.4.2.5.4	SECTION 417.104	417.104 Payment for basic health services.
42:3.0.1.1.4.2.5.5	SECTION 417.105	417.105 Payment for supplemental health services.
42:3.0.1.1.4.2.5.6	SECTION 417.106	417.106 Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
42:3.0.1.1.4.3	SUBPART C	Subpart C - Qualified Health Maintenance Organizations: Organization and Operation
42:3.0.1.1.4.3.5.1	SECTION 417.120	417.120 Fiscally sound operation and assumption of financial risk.
42:3.0.1.1.4.3.5.2	SECTION 417.122	417.122 Protection of enrollees.
42:3.0.1.1.4.3.5.3	SECTION 417.124	417.124 Administration and management.
42:3.0.1.1.4.3.5.4	SECTION 417.126	417.126 Recordkeeping and reporting requirements.
42:3.0.1.1.4.4	SUBPART D	Subpart D - Application for Federal Qualification
42:3.0.1.1.4.4.5.1	SECTION 417.140	417.140 Scope.
42:3.0.1.1.4.4.5.2	SECTION 417.142	417.142 Requirements for qualification.
42:3.0.1.1.4.4.5.3	SECTION 417.143	417.143 Application requirements.
42:3.0.1.1.4.4.5.4	SECTION 417.144	417.144 Evaluation and determination procedures.
42:3.0.1.1.4.5	SUBPART E	Subpart E - Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans
42:3.0.1.1.4.5.5.1	SECTION 417.150	417.150 Definitions.
42:3.0.1.1.4.5.5.2	SECTION 417.151	417.151 Applicability.
42:3.0.1.1.4.5.5.3	SECTION 417.153	417.153 Offer of HMO alternative.
42:3.0.1.1.4.5.5.4	SECTION 417.155	417.155 How the HMO option must be included in the health benefits plan.
42:3.0.1.1.4.5.5.5	SECTION 417.156	417.156 When the HMO must be offered to employees.
42:3.0.1.1.4.5.5.6	SECTION 417.157	417.157 Contributions for the HMO alternative.
42:3.0.1.1.4.5.5.7	SECTION 417.158	417.158 Payroll deductions.
42:3.0.1.1.4.5.5.8	SECTION 417.159	417.159 Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
42:3.0.1.1.4.6	SUBPART F	Subpart F - Continued Regulation of Federally Qualified Health Maintenance Organizations
42:3.0.1.1.4.6.5.1	SECTION 417.160	417.160 Applicability.
42:3.0.1.1.4.6.5.2	SECTION 417.161	417.161 Compliance with assurances.
42:3.0.1.1.4.6.5.3	SECTION 417.162	417.162 Reporting requirements.
42:3.0.1.1.4.6.5.4	SECTION 417.163	417.163 Enforcement procedures.
42:3.0.1.1.4.6.5.5	SECTION 417.164	417.164 Effect of revocation of qualification on inclusion in employee's health benefit plans.
42:3.0.1.1.4.6.5.6	SECTION 417.165	417.165 Reapplication for qualification.
42:3.0.1.1.4.6.5.7	SECTION 417.166	417.166 Waiver of assurances.
42:3.0.1.1.4.7	SUBPART G	Subparts G-I [Reserved]
42:3.0.1.1.4.8	SUBPART J	Subpart J - Qualifying Conditions for Medicare Contracts
42:3.0.1.1.4.8.5.1	SECTION 417.400	417.400 Basis and scope.
42:3.0.1.1.4.8.5.2	SECTION 417.401	417.401 Definitions.
42:3.0.1.1.4.8.5.3	SECTION 417.402	417.402 Effective date of initial regulations.
42:3.0.1.1.4.8.5.4	SECTION 417.404	417.404 General requirements.
42:3.0.1.1.4.8.5.5	SECTION 417.406	417.406 Application and determination.
42:3.0.1.1.4.8.5.6	SECTION 417.407	417.407 Requirements for a Competitive Medical Plan (CMP).
42:3.0.1.1.4.8.5.7	SECTION 417.408	417.408 Contract application process.
42:3.0.1.1.4.8.5.8	SECTION 417.410	417.410 Qualifying conditions: General rules.
42:3.0.1.1.4.8.5.9	SECTION 417.412	417.412 Qualifying condition: Administration and management.
42:3.0.1.1.4.8.5.10	SECTION 417.413	417.413 Qualifying condition: Operating experience and enrollment.
42:3.0.1.1.4.8.5.11	SECTION 417.414	417.414 Qualifying condition: Range of services.
42:3.0.1.1.4.8.5.12	SECTION 417.416	417.416 Qualifying condition: Furnishing of services.
42:3.0.1.1.4.8.5.13	SECTION 417.418	417.418 Qualifying condition: Quality assurance program.
42:3.0.1.1.4.9	SUBPART K	Subpart K - Enrollment, Entitlement, and Disenrollment under Medicare Contract
42:3.0.1.1.4.9.5.1	SECTION 417.420	417.420 Basic rules on enrollment and entitlement.
42:3.0.1.1.4.9.5.2	SECTION 417.422	417.422 Eligibility to enroll in an HMO or CMP.
42:3.0.1.1.4.9.5.3	SECTION 417.423	417.423 Special rules: ESRD and hospice patients.
42:3.0.1.1.4.9.5.4	SECTION 417.424	417.424 Denial of enrollment.
42:3.0.1.1.4.9.5.5	SECTION 417.426	417.426 Open enrollment requirements.
42:3.0.1.1.4.9.5.6	SECTION 417.427	417.427 Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
42:3.0.1.1.4.9.5.7	SECTION 417.428	417.428 Marketing activities.
42:3.0.1.1.4.9.5.8	SECTION 417.430	417.430 Application procedures.
42:3.0.1.1.4.9.5.9	SECTION 417.432	417.432 Conversion of enrollment.
42:3.0.1.1.4.9.5.10	SECTION 417.434	417.434 Reenrollment.
42:3.0.1.1.4.9.5.11	SECTION 417.436	417.436 Rules for enrollees.
42:3.0.1.1.4.9.5.12	SECTION 417.440	417.440 Entitlement to health care services from an HMO or CMP.
42:3.0.1.1.4.9.5.13	SECTION 417.442	417.442 Risk HMO's and CMP's: Conditions for provision of additional benefits.
42:3.0.1.1.4.9.5.14	SECTION 417.444	417.444 Special rules for certain enrollees of risk HMOs and CMPs.
42:3.0.1.1.4.9.5.15	SECTION 417.446	417.446 [Reserved]
42:3.0.1.1.4.9.5.16	SECTION 417.448	417.448 Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
42:3.0.1.1.4.9.5.17	SECTION 417.450	417.450 Effective date of coverage.
42:3.0.1.1.4.9.5.18	SECTION 417.452	417.452 Liability of Medicare enrollees.
42:3.0.1.1.4.9.5.19	SECTION 417.454	417.454 Charges to Medicare enrollees.
42:3.0.1.1.4.9.5.20	SECTION 417.456	417.456 Refunds to Medicare enrollees.
42:3.0.1.1.4.9.5.21	SECTION 417.458	417.458 Recoupment of uncollected deductible and coinsurance amounts.
42:3.0.1.1.4.9.5.22	SECTION 417.460	417.460 Disenrollment of beneficiaries by an HMO or CMP.
42:3.0.1.1.4.9.5.23	SECTION 417.461	417.461 Disenrollment by the enrollee.
42:3.0.1.1.4.9.5.24	SECTION 417.464	417.464 End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
42:3.0.1.1.4.10	SUBPART L	Subpart L - Medicare Contract Requirements
42:3.0.1.1.4.10.5.1	SECTION 417.470	417.470 Basis and scope.
42:3.0.1.1.4.10.5.2	SECTION 417.472	417.472 Basic contract requirements.
42:3.0.1.1.4.10.5.3	SECTION 417.474	417.474 Effective date and term of contract.
42:3.0.1.1.4.10.5.4	SECTION 417.476	417.476 Waived conditions.
42:3.0.1.1.4.10.5.5	SECTION 417.478	417.478 Requirements of other laws and regulations.
42:3.0.1.1.4.10.5.6	SECTION 417.479	417.479 Requirements for physician incentive plans.
42:3.0.1.1.4.10.5.7	SECTION 417.480	417.480 Maintenance of records: Cost HMOs and CMPs.
42:3.0.1.1.4.10.5.8	SECTION 417.481	417.481 Maintenance of records: Risk HMOs and CMPs.
42:3.0.1.1.4.10.5.9	SECTION 417.482	417.482 Access to facilities and records.
42:3.0.1.1.4.10.5.10	SECTION 417.484	417.484 Requirement applicable to related entities.
42:3.0.1.1.4.10.5.11	SECTION 417.486	417.486 Disclosure of information and confidentiality.
42:3.0.1.1.4.10.5.12	SECTION 417.488	417.488 Notice of termination and of available alternatives: Risk contract.
42:3.0.1.1.4.10.5.13	SECTION 417.490	417.490 Renewal of contract.
42:3.0.1.1.4.10.5.14	SECTION 417.492	417.492 Nonrenewal of contract.
42:3.0.1.1.4.10.5.15	SECTION 417.494	417.494 Modification or termination of contract.
42:3.0.1.1.4.10.5.16	SECTION 417.496	417.496 xxx
42:3.0.1.1.4.10.5.17	SECTION 417.500	417.500 Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
42:3.0.1.1.4.11	SUBPART M	Subpart M - Change of Ownership and Leasing of Facilities: Effect on Medicare Contract
42:3.0.1.1.4.11.5.1	SECTION 417.520	417.520 Effect on HMO and CMP contracts.
42:3.0.1.1.4.12	SUBPART N	Subpart N - Medicare Payment to HMOs and CMPs: General Rules
42:3.0.1.1.4.12.5.1	SECTION 417.524	417.524 Payment to HMOs or CMPs: General.
42:3.0.1.1.4.12.5.2	SECTION 417.526	417.526 Payment for covered services.
42:3.0.1.1.4.12.5.3	SECTION 417.528	417.528 Payment when Medicare is not primary payer.
42:3.0.1.1.4.13	SUBPART O	Subpart O - Medicare Payment: Cost Basis
42:3.0.1.1.4.13.5.1	SECTION 417.530	417.530 Basis and scope.
42:3.0.1.1.4.13.5.2	SECTION 417.531	417.531 Hospice care services.
42:3.0.1.1.4.13.5.3	SECTION 417.532	417.532 General considerations.
42:3.0.1.1.4.13.5.4	SECTION 417.533	417.533 Part B carrier responsibilities.
42:3.0.1.1.4.13.5.5	SECTION 417.534	417.534 Allowable costs.
42:3.0.1.1.4.13.5.6	SECTION 417.536	417.536 Cost payment principles.
42:3.0.1.1.4.13.5.7	SECTION 417.538	417.538 Enrollment and marketing costs.
42:3.0.1.1.4.13.5.8	SECTION 417.540	417.540 Enrollment costs.
42:3.0.1.1.4.13.5.9	SECTION 417.542	417.542 Reinsurance costs.
42:3.0.1.1.4.13.5.10	SECTION 417.544	417.544 Physicians' services furnished directly by the HMO or CMP.
42:3.0.1.1.4.13.5.11	SECTION 417.546	417.546 Physicians' services and other Part B supplier services furnished under arrangements.
42:3.0.1.1.4.13.5.12	SECTION 417.548	417.548 Provider services through arrangements.
42:3.0.1.1.4.13.5.13	SECTION 417.550	417.550 Special Medicare program requirements.
42:3.0.1.1.4.13.5.14	SECTION 417.552	417.552 Cost apportionment: General provisions.
42:3.0.1.1.4.13.5.15	SECTION 417.554	417.554 Apportionment: Provider services furnished directly by the HMO or CMP.
42:3.0.1.1.4.13.5.16	SECTION 417.556	417.556 Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
42:3.0.1.1.4.13.5.17	SECTION 417.558	417.558 Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
42:3.0.1.1.4.13.5.18	SECTION 417.560	417.560 Apportionment: Part B physician and supplier services.
42:3.0.1.1.4.13.5.19	SECTION 417.564	417.564 Apportionment and allocation of administrative and general costs.
42:3.0.1.1.4.13.5.20	SECTION 417.566	417.566 Other methods of allocation and apportionment.
42:3.0.1.1.4.13.5.21	SECTION 417.568	417.568 Adequate financial records, statistical data, and cost finding.
42:3.0.1.1.4.13.5.22	SECTION 417.570	417.570 Interim per capita payments.
42:3.0.1.1.4.13.5.23	SECTION 417.572	417.572 Budget and enrollment forecast and interim reports.
42:3.0.1.1.4.13.5.24	SECTION 417.574	417.574 Interim settlement.
42:3.0.1.1.4.13.5.25	SECTION 417.576	417.576 Final settlement.
42:3.0.1.1.4.14	SUBPART P	Subpart P - Medicare Payment: Risk Basis
42:3.0.1.1.4.14.5.1	SECTION 417.580	417.580 Basis and scope.
42:3.0.1.1.4.14.5.2	SECTION 417.582	417.582 Definitions.
42:3.0.1.1.4.14.5.3	SECTION 417.584	417.584 Payment to HMOs or CMPs with risk contracts.
42:3.0.1.1.4.14.5.4	SECTION 417.585	417.585 Special rules: Hospice care.
42:3.0.1.1.4.14.5.5	SECTION 417.588	417.588 Computation of adjusted average per capita cost (AAPCC).
42:3.0.1.1.4.14.5.6	SECTION 417.590	417.590 Computation of the average of the per capita rates of payment.
42:3.0.1.1.4.14.5.7	SECTION 417.592	417.592 Additional benefits requirement.
42:3.0.1.1.4.14.5.8	SECTION 417.594	417.594 Computation of adjusted community rate (ACR).
42:3.0.1.1.4.14.5.9	SECTION 417.596	417.596 Establishment of a benefit stabilization fund.
42:3.0.1.1.4.14.5.10	SECTION 417.597	417.597 Withdrawal from a benefit stabilization fund.
42:3.0.1.1.4.14.5.11	SECTION 417.598	417.598 Annual enrollment reconciliation.
42:3.0.1.1.4.15	SUBPART Q	Subpart Q - Beneficiary Appeals
42:3.0.1.1.4.15.5.1	SECTION 417.600	417.600 Basis and scope.
42:3.0.1.1.4.16	SUBPART R	Subpart R - Medicare Contract Appeals
42:3.0.1.1.4.16.5.1	SECTION 417.640	417.640 Applicability.
42:3.0.1.1.4.17	SUBPART S	Subparts S-T [Reserved]
42:3.0.1.1.4.18	SUBPART U	Subpart U - Health Care Prepayment Plans
42:3.0.1.1.4.18.5.1	SECTION 417.800	417.800 Payment to HCPPs: Definitions and basic rules.
42:3.0.1.1.4.18.5.2	SECTION 417.801	417.801 Agreements between CMS and health care prepayment plans.
42:3.0.1.1.4.18.5.3	SECTION 417.802	417.802 Allowable costs.
42:3.0.1.1.4.18.5.4	SECTION 417.804	417.804 Cost apportionment.
42:3.0.1.1.4.18.5.5	SECTION 417.806	417.806 Financial records, statistical data, and cost finding.
42:3.0.1.1.4.18.5.6	SECTION 417.808	417.808 Interim per capita payments.
42:3.0.1.1.4.18.5.7	SECTION 417.810	417.810 Final settlement.
42:3.0.1.1.4.18.5.8	SECTION 417.830	417.830 Scope of regulations on beneficiary appeals.
42:3.0.1.1.4.18.5.9	SECTION 417.832	417.832 Applicability of requirements and procedures.
42:3.0.1.1.4.18.5.10	SECTION 417.834	417.834 Responsibility for establishing administrative review procedures.
42:3.0.1.1.4.18.5.11	SECTION 417.836	417.836 Written description of administrative review procedures.
42:3.0.1.1.4.18.5.12	SECTION 417.838	417.838 Organization determinations.
42:3.0.1.1.4.18.5.13	SECTION 417.840	417.840 Administrative review procedures.
42:3.0.1.1.4.19	SUBPART V	Subpart V - Administration of Outstanding Loans and Loan Guarantees
42:3.0.1.1.4.19.5.1	SECTION 417.910	417.910 Applicability.
42:3.0.1.1.4.19.5.2	SECTION 417.911	417.911 Definitions.
42:3.0.1.1.4.19.5.3	SECTION 417.920	417.920 Planning and initial development.
42:3.0.1.1.4.19.5.4	SECTION 417.930	417.930 Initial costs of operation.
42:3.0.1.1.4.19.5.5	SECTION 417.931	417.931 [Reserved]
42:3.0.1.1.4.19.5.6	SECTION 417.934	417.934 Reserve requirement.
42:3.0.1.1.4.19.5.7	SECTION 417.937	417.937 Loan and loan guarantee provisions.
42:3.0.1.1.4.19.5.8	SECTION 417.940	417.940 Civil action to enforce compliance with assurances.
42:3.0.1.1.5	PART 418	PART 418 - HOSPICE CARE
42:3.0.1.1.5.1	SUBPART A	Subpart A - General Provision and Definitions
42:3.0.1.1.5.1.7.1	SECTION 418.1	418.1 Statutory basis.
42:3.0.1.1.5.1.7.2	SECTION 418.2	418.2 Scope of part.
42:3.0.1.1.5.1.7.3	SECTION 418.3	418.3 Definitions.
42:3.0.1.1.5.2	SUBPART B	Subpart B - Eligibility, Election and Duration of Benefits
42:3.0.1.1.5.2.7.1	SECTION 418.20	418.20 Eligibility requirements.
42:3.0.1.1.5.2.7.2	SECTION 418.21	418.21 Duration of hospice care coverage - Election periods.
42:3.0.1.1.5.2.7.3	SECTION 418.22	418.22 Certification of terminal illness.
42:3.0.1.1.5.2.7.4	SECTION 418.24	418.24 Election of hospice care.
42:3.0.1.1.5.2.7.5	SECTION 418.25	418.25 Admission to hospice care.
42:3.0.1.1.5.2.7.6	SECTION 418.26	418.26 Discharge from hospice care.
42:3.0.1.1.5.2.7.7	SECTION 418.28	418.28 Revoking the election of hospice care.
42:3.0.1.1.5.2.7.8	SECTION 418.30	418.30 Change of the designated hospice.
42:3.0.1.1.5.3	SUBPART C	Subpart C - Conditions of Participation: Patient Care
42:3.0.1.1.5.3.7	SUBJGRP 7	Core Services
42:3.0.1.1.5.3.7.1	SECTION 418.52	418.52 Condition of participation: Patient's rights.
42:3.0.1.1.5.3.7.2	SECTION 418.54	418.54 Condition of participation: Initial and comprehensive assessment of the patient.
42:3.0.1.1.5.3.7.3	SECTION 418.56	418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services.
42:3.0.1.1.5.3.7.4	SECTION 418.58	418.58 Condition of participation: Quality assessment and performance improvement.
42:3.0.1.1.5.3.7.5	SECTION 418.60	418.60 Condition of participation: Infection control.
42:3.0.1.1.5.3.7.6	SECTION 418.62	418.62 Condition of participation: Licensed professional services.
42:3.0.1.1.5.3.7.7	SECTION 418.64	418.64 Condition of participation: Core services.
42:3.0.1.1.5.3.7.8	SECTION 418.66	418.66 Condition of participation: Nursing services - Waiver of requirement that substantially all nursing services be routinely provided directly by a hospice.
42:3.0.1.1.5.3.8	SUBJGRP 8	Non-Core Services
42:3.0.1.1.5.3.8.9	SECTION 418.70	418.70 Condition of participation: Furnishing of non-core services.
42:3.0.1.1.5.3.8.10	SECTION 418.72	418.72 Condition of participation: Physical therapy, occupational therapy, and speech-language pathology.
42:3.0.1.1.5.3.8.11	SECTION 418.74	418.74 Waiver of requirement - Physical therapy, occupational therapy, speech-language pathology, and dietary counseling.
42:3.0.1.1.5.3.8.12	SECTION 418.76	418.76 Condition of participation: Hospice aide and homemaker services.
42:3.0.1.1.5.3.8.13	SECTION 418.78	418.78 Conditions of participation - Volunteers.
42:3.0.1.1.5.4	SUBPART D	Subpart D - Conditions of participation: Organizational Environment
42:3.0.1.1.5.4.9.1	SECTION 418.100	418.100 Condition of Participation: Organization and administration of services.
42:3.0.1.1.5.4.9.2	SECTION 418.102	418.102 Condition of participation: Medical director.
42:3.0.1.1.5.4.9.3	SECTION 418.104	418.104 Condition of participation: Clinical records.
42:3.0.1.1.5.4.9.4	SECTION 418.106	418.106 Condition of participation: Drugs and biologicals, medical supplies, and durable medical equipment.
42:3.0.1.1.5.4.9.5	SECTION 418.108	418.108 Condition of participation: Short-term inpatient care.
42:3.0.1.1.5.4.9.6	SECTION 418.110	418.110 Condition of participation: Hospices that provide inpatient care directly.
42:3.0.1.1.5.4.9.7	SECTION 418.112	418.112 Condition of participation: Hospices that provide hospice care to residents of a SNF/NF or ICF/IID.
42:3.0.1.1.5.4.9.8	SECTION 418.113	418.113 Condition of participation: Emergency preparedness.
42:3.0.1.1.5.4.9.9	SECTION 418.114	418.114 Condition of participation: Personnel qualifications.
42:3.0.1.1.5.4.9.10	SECTION 418.116	418.116 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.
42:3.0.1.1.5.5	SUBPART E	Subpart E [Reserved]
42:3.0.1.1.5.6	SUBPART F	Subpart F - Covered Services
42:3.0.1.1.5.6.9.1	SECTION 418.200	418.200 Requirements for coverage.
42:3.0.1.1.5.6.9.2	SECTION 418.202	418.202 Covered services.
42:3.0.1.1.5.6.9.3	SECTION 418.204	418.204 Special coverage requirements.
42:3.0.1.1.5.6.9.4	SECTION 418.205	418.205 Special requirements for hospice pre-election evaluation and counseling services.
42:3.0.1.1.5.7	SUBPART G	Subpart G - Payment for Hospice Care
42:3.0.1.1.5.7.9.1	SECTION 418.301	418.301 Basic rules.
42:3.0.1.1.5.7.9.2	SECTION 418.302	418.302 Payment procedures for hospice care.
42:3.0.1.1.5.7.9.3	SECTION 418.304	418.304 Payment for physician, and nurse practitioner, and physician assistant services.
42:3.0.1.1.5.7.9.4	SECTION 418.306	418.306 Annual update of the payment rates and adjustment for area wage differences.
42:3.0.1.1.5.7.9.5	SECTION 418.307	418.307 Periodic interim payments.
42:3.0.1.1.5.7.9.6	SECTION 418.308	418.308 Limitation on the amount of hospice payments.
42:3.0.1.1.5.7.9.7	SECTION 418.309	418.309 Hospice aggregate cap.
42:3.0.1.1.5.7.9.8	SECTION 418.310	418.310 Reporting and recordkeeping requirements.
42:3.0.1.1.5.7.9.9	SECTION 418.311	418.311 Administrative appeals.
42:3.0.1.1.5.7.9.10	SECTION 418.312	418.312 Data submission requirements under the hospice quality reporting program.
42:3.0.1.1.5.8	SUBPART H	Subpart H - Coinsurance
42:3.0.1.1.5.8.9.1	SECTION 418.400	418.400 Individual liability for coinsurance for hospice care.
42:3.0.1.1.5.8.9.2	SECTION 418.402	418.402 Individual liability for services that are not considered hospice care.
42:3.0.1.1.5.8.9.3	SECTION 418.405	418.405 Effect of coinsurance liability on Medicare payment.
42:3.0.1.1.6	PART 419	PART 419 - PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES
42:3.0.1.1.6.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.6.1.9.1	SECTION 419.1	419.1 Basis and scope.
42:3.0.1.1.6.1.9.2	SECTION 419.2	419.2 Basis of payment.
42:3.0.1.1.6.2	SUBPART B	Subpart B - Categories of Hospitals and Services Subject to and Excluded From the Hospital Outpatient Prospective Payment System
42:3.0.1.1.6.2.9.1	SECTION 419.20	419.20 Hospitals subject to the hospital outpatient prospective payment system.
42:3.0.1.1.6.2.9.2	SECTION 419.21	419.21 Hospital services subject to the outpatient prospective payment system.
42:3.0.1.1.6.2.9.3	SECTION 419.22	419.22 Hospital services excluded from payment under the hospital outpatient prospective payment system.
42:3.0.1.1.6.3	SUBPART C	Subpart C - Basic Methodology for Determining Prospective Payment Rates for Hospital Outpatient Services
42:3.0.1.1.6.3.9.1	SECTION 419.30	419.30 Base expenditure target for calendar year 1999.
42:3.0.1.1.6.3.9.2	SECTION 419.31	419.31 Ambulatory payment classification (APC) system and payment weights.
42:3.0.1.1.6.3.9.3	SECTION 419.32	419.32 Calculation of prospective payment rates for hospital outpatient services.
42:3.0.1.1.6.4	SUBPART D	Subpart D - Payments to Hospitals
42:3.0.1.1.6.4.9.1	SECTION 419.40	419.40 Payment concepts.
42:3.0.1.1.6.4.9.2	SECTION 419.41	419.41 Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.
42:3.0.1.1.6.4.9.3	SECTION 419.42	419.42 Hospital election to reduce coinsurance.
42:3.0.1.1.6.4.9.4	SECTION 419.43	419.43 Adjustments to national program payment and beneficiary copayment amounts.
42:3.0.1.1.6.4.9.5	SECTION 419.44	419.44 Payment reductions for procedures.
42:3.0.1.1.6.4.9.6	SECTION 419.45	419.45 Payment and copayment reduction for devices replaced without cost or when full or partial credit is received.
42:3.0.1.1.6.4.9.7	SECTION 419.46	419.46 Participation, data submission, and validation requirements under the Hospital Outpatient Quality Reporting (OQR) Program.
42:3.0.1.1.6.4.9.8	SECTION 419.48	419.48 Definition of excepted items and services.
42:3.0.1.1.6.5	SUBPART E	Subpart E - Updates
42:3.0.1.1.6.5.9.1	SECTION 419.50	419.50 Annual review.
42:3.0.1.1.6.6	SUBPART F	Subpart F - Limitations on Review
42:3.0.1.1.6.6.9.1	SECTION 419.60	419.60 Limitations on administrative and judicial review.
42:3.0.1.1.6.7	SUBPART G	Subpart G - Transitional Pass-through Payments
42:3.0.1.1.6.7.9.1	SECTION 419.62	419.62 Transitional pass-through payments: General rules.
42:3.0.1.1.6.7.9.2	SECTION 419.64	419.64 Transitional pass-through payments: Drugs and biologicals.
42:3.0.1.1.6.7.9.3	SECTION 419.66	419.66 Transitional pass-through payments: Medical devices.
42:3.0.1.1.6.8	SUBPART H	Subpart H - Transitional Corridors
42:3.0.1.1.6.8.9.1	SECTION 419.70	419.70 Transitional adjustments to limit decline in payments.
42:3.0.1.1.6.8.9.2	SECTION 419.71	419.71 Payment reduction for certain X-ray imaging services.
42:3.0.1.1.6.9	SUBPART I	Subpart I - Prior Authorization for Outpatient Department Services
42:3.0.1.1.6.9.9.1	SECTION 419.80	419.80 Basis and scope of this subpart.
42:3.0.1.1.6.9.9.2	SECTION 419.81	419.81 Definitions.
42:3.0.1.1.6.9.9.3	SECTION 419.82	419.82 Prior authorization for certain covered hospital outpatient department services.
42:3.0.1.1.6.9.9.4	SECTION 419.83	419.83 List of hospital outpatient department services requiring prior authorization.
42:3.0.1.1.6.9.9.5	SECTION 419.84-419.89	419.84-419.89 [Reserved]
42:3.0.1.1.7	PART 420	PART 420 - PROGRAM INTEGRITY: MEDICARE
42:3.0.1.1.7.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.7.1.9.1	SECTION 420.1	420.1 Scope and purpose.
42:3.0.1.1.7.1.9.2	SECTION 420.3	420.3 Other related regulations.
42:3.0.1.1.7.2	SUBPART B	Subpart B [Reserved]
42:3.0.1.1.7.3	SUBPART C	Subpart C - Disclosure of Ownership and Control Information
42:3.0.1.1.7.3.9.1	SECTION 420.200	420.200 Purpose.
42:3.0.1.1.7.3.9.2	SECTION 420.201	420.201 Definitions.
42:3.0.1.1.7.3.9.3	SECTION 420.202	420.202 Determination of ownership or control percentages.
42:3.0.1.1.7.3.9.4	SECTION 420.203	420.203 Disclosure of hiring of intermediary's former employees.
42:3.0.1.1.7.3.9.5	SECTION 420.204	420.204 Principals convicted of a program-related crime.
42:3.0.1.1.7.3.9.6	SECTION 420.205	420.205 Disclosure by providers and part B suppliers of business transaction information.
42:3.0.1.1.7.3.9.7	SECTION 420.206	420.206 Disclosure of persons having ownership, financial, or control interest.
42:3.0.1.1.7.4	SUBPART D	Subpart D - Access to Books, Documents, and Records of Subcontractors
42:3.0.1.1.7.4.9.1	SECTION 420.300	420.300 Basis, purpose, and scope.
42:3.0.1.1.7.4.9.2	SECTION 420.301	420.301 Definitions.
42:3.0.1.1.7.4.9.3	SECTION 420.302	420.302 Requirement for access clause in contracts.
42:3.0.1.1.7.4.9.4	SECTION 420.303	420.303 HHS criteria for requesting books, documents, and records.
42:3.0.1.1.7.4.9.5	SECTION 420.304	420.304 Procedures for obtaining access to books, documents, and records.
42:3.0.1.1.7.5	SUBPART E	Subpart E - Rewards for Information Relating to Medicare Fraud and Abuse, and Establishment of a Program to Collect Suggestions for Improving Medicare Program Efficiency and to Reward Suggesters for Monetary Savings
42:3.0.1.1.7.5.9.1	SECTION 420.400	420.400 Basis and scope.
42:3.0.1.1.7.5.9.2	SECTION 420.405	420.405 Rewards for information relating to Medicare fraud and abuse.
42:3.0.1.1.7.5.9.3	SECTION 420.410	420.410 Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary savings.
42:3.0.1.1.8	PART 421	PART 421 - MEDICARE CONTRACTING
42:3.0.1.1.8.1	SUBPART A	Subpart A - Scope, Definitions, and General Provisions
42:3.0.1.1.8.1.9.1	SECTION 421.1	421.1 Basis, applicability, and scope.
42:3.0.1.1.8.1.9.2	SECTION 421.3	421.3 Definitions.
42:3.0.1.1.8.1.9.3	SECTION 421.5	421.5 General provisions.
42:3.0.1.1.8.2	SUBPART B	Subpart B - Intermediaries
42:3.0.1.1.8.2.9.1	SECTION 421.100	421.100 Intermediary functions.
42:3.0.1.1.8.2.9.2	SECTION 421.103	421.103 Payment to providers.
42:3.0.1.1.8.2.9.3	SECTION 421.104	421.104 Assignment of providers of services to intermediaries during transition to Medicare Administrative Contractors (MACs).
42:3.0.1.1.8.2.9.4	SECTION 421.110	421.110 Requirements for approval of an agreement.
42:3.0.1.1.8.2.9.5	SECTION 421.112	421.112 Considerations relating to the effective and efficient administration of the program.
42:3.0.1.1.8.2.9.6	SECTION 421.114	421.114 Assignment and reassignment of providers by CMS.
42:3.0.1.1.8.2.9.7	SECTION 421.120	421.120 Performance criteria.
42:3.0.1.1.8.2.9.8	SECTION 421.122	421.122 Performance standards.
42:3.0.1.1.8.2.9.9	SECTION 421.124	421.124 Intermediary's failure to perform efficiently and effectively.
42:3.0.1.1.8.2.9.10	SECTION 421.126	421.126 Termination of agreements.
42:3.0.1.1.8.2.9.11	SECTION 421.128	421.128 Intermediary's opportunity for hearing and right to judicial review.
42:3.0.1.1.8.3	SUBPART C	Subpart C - Carriers
42:3.0.1.1.8.3.9.1	SECTION 421.200	421.200 Carrier functions.
42:3.0.1.1.8.3.9.2	SECTION 421.201	421.201 Performance criteria and standards.
42:3.0.1.1.8.3.9.3	SECTION 421.202	421.202 Requirements and conditions.
42:3.0.1.1.8.3.9.4	SECTION 421.203	421.203 Carrier's failure to perform efficiently and effectively.
42:3.0.1.1.8.3.9.5	SECTION 421.205	421.205 Termination by the Secretary.
42:3.0.1.1.8.3.9.6	SECTION 421.210	421.210 Designations of regional carriers to process claims for durable medical equipment, prosthetics, orthotics and supplies.
42:3.0.1.1.8.3.9.7	SECTION 421.212	421.212 Railroad Retirement Board contracts.
42:3.0.1.1.8.3.9.8	SECTION 421.214	421.214 Advance payments to suppliers furnishing items or services under Part B.
42:3.0.1.1.8.4	SUBPART D	Subpart D - Medicare Integrity Program Contractors
42:3.0.1.1.8.4.9.1	SECTION 421.300	421.300 Basis, applicability, and scope.
42:3.0.1.1.8.4.9.2	SECTION 421.302	421.302 Eligibility requirements for Medicare integrity program contractors.
42:3.0.1.1.8.4.9.3	SECTION 421.304	421.304 Medicare integrity program contractor functions.
42:3.0.1.1.8.4.9.4	SECTION 421.306	421.306 Awarding of a contract.
42:3.0.1.1.8.4.9.5	SECTION 421.308	421.308 Renewal of a contract.
42:3.0.1.1.8.4.9.6	SECTION 421.310	421.310 Conflict of interest requirements.
42:3.0.1.1.8.4.9.7	SECTION 421.312	421.312 Conflict of interest resolution.
42:3.0.1.1.8.4.9.8	SECTION 421.316	421.316 Limitation on Medicare integrity program contractor liability.
42:3.0.1.1.8.5	SUBPART E	Subpart E - Medicare Administrative Contractors (MACs)
42:3.0.1.1.8.5.9.1	SECTION 421.400	421.400 Statutory basis and scope.
42:3.0.1.1.8.5.9.2	SECTION 421.401	421.401 Definitions.
42:3.0.1.1.8.5.9.3	SECTION 421.404	421.404 Assignment of providers and suppliers to MACs.
42:3.0.1.1.8.6	SUBPART F	Subpart F [Reserved]
42:3.0.1.1.9	PART 422	PART 422 - MEDICARE ADVANTAGE PROGRAM
42:3.0.1.1.9.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.9.1.10.1	SECTION 422.1	422.1 Basis and scope.
42:3.0.1.1.9.1.10.2	SECTION 422.2	422.2 Definitions.
42:3.0.1.1.9.1.10.3	SECTION 422.3	422.3 MA organizations' use of reinsurance.
42:3.0.1.1.9.1.10.4	SECTION 422.4	422.4 Types of MA plans.
42:3.0.1.1.9.1.10.5	SECTION 422.6	422.6 Cost-sharing in enrollment-related costs.
42:3.0.1.1.9.2	SUBPART B	Subpart B - Eligibility, Election, and Enrollment
42:3.0.1.1.9.2.10.1	SECTION 422.50	422.50 Eligibility to elect an MA plan.
42:3.0.1.1.9.2.10.2	SECTION 422.52	422.52 Eligibility to elect an MA plan for special needs individuals.
42:3.0.1.1.9.2.10.3	SECTION 422.53	422.53 Eligibility to elect an MA plan for senior housing facility residents.
42:3.0.1.1.9.2.10.4	SECTION 422.54	422.54 Continuation of enrollment for MA local plans.
42:3.0.1.1.9.2.10.5	SECTION 422.56	422.56 Enrollment in an MA MSA plan.
42:3.0.1.1.9.2.10.6	SECTION 422.57	422.57 Limited enrollment under MA RFB plans.
42:3.0.1.1.9.2.10.7	SECTION 422.60	422.60 Election process.
42:3.0.1.1.9.2.10.8	SECTION 422.62	422.62 Election of coverage under an MA plan.
42:3.0.1.1.9.2.10.9	SECTION 422.64	422.64 Information about the MA program.
42:3.0.1.1.9.2.10.10	SECTION 422.66	422.66 Coordination of enrollment and disenrollment through MA organizations.
42:3.0.1.1.9.2.10.11	SECTION 422.68	422.68 Effective dates of coverage and change of coverage.
42:3.0.1.1.9.2.10.12	SECTION 422.74	422.74 Disenrollment by the MA organization.
42:3.0.1.1.9.3	SUBPART C	Subpart C - Benefits and Beneficiary Protections
42:3.0.1.1.9.3.10.1	SECTION 422.100	422.100 General requirements.
42:3.0.1.1.9.3.10.2	SECTION 422.101	422.101 Requirements relating to basic benefits.
42:3.0.1.1.9.3.10.3	SECTION 422.102	422.102 Supplemental benefits.
42:3.0.1.1.9.3.10.4	SECTION 422.103	422.103 Benefits under an MA MSA plan.
42:3.0.1.1.9.3.10.5	SECTION 422.104	422.104 Special rules on supplemental benefits for MA MSA plans.
42:3.0.1.1.9.3.10.6	SECTION 422.105	422.105 Special rules for self-referral and point of service option.
42:3.0.1.1.9.3.10.7	SECTION 422.106	422.106 Coordination of benefits with employer or union group health plans and Medicaid.
42:3.0.1.1.9.3.10.8	SECTION 422.107	422.107 Special needs plans and dual eligibles: Contract with State Medicaid Agency.
42:3.0.1.1.9.3.10.9	SECTION 422.108	422.108 Medicare secondary payer (MSP) procedures.
42:3.0.1.1.9.3.10.10	SECTION 422.109	422.109 Effect of national coverage determinations (NCDs) and legislative changes in benefits.
42:3.0.1.1.9.3.10.11	SECTION 422.110	422.110 Discrimination against beneficiaries prohibited.
42:3.0.1.1.9.3.10.12	SECTION 422.111	422.111 Disclosure requirements.
42:3.0.1.1.9.3.10.13	SECTION 422.112	422.112 Access to services.
42:3.0.1.1.9.3.10.14	SECTION 422.113	422.113 Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services.
42:3.0.1.1.9.3.10.15	SECTION 422.114	422.114 Access to services under an MA private fee-for-service plan.
42:3.0.1.1.9.3.10.16	SECTION 422.116	422.116 Network adequacy.
42:3.0.1.1.9.3.10.17	SECTION 422.118	422.118 Confidentiality and accuracy of enrollee records.
42:3.0.1.1.9.3.10.18	SECTION 422.119	422.119 Access to and exchange of health data and plan information.
42:3.0.1.1.9.3.10.19	SECTION 422.120	422.120 Access to published provider directory information.
42:3.0.1.1.9.3.10.20	SECTION 422.128	422.128 Information on advance directives.
42:3.0.1.1.9.3.10.21	SECTION 422.132	422.132 Protection against liability and loss of benefits.
42:3.0.1.1.9.3.10.22	SECTION 422.133	422.133 Return to home skilled nursing facility.
42:3.0.1.1.9.3.10.23	SECTION 422.134	422.134 Reward and incentive programs.
42:3.0.1.1.9.3.10.24	SECTION 422.135	422.135 Additional telehealth benefits.
42:3.0.1.1.9.3.10.25	SECTION 422.136	422.136 Medicare Advantage (MA) and step therapy for Part B drugs.
42:3.0.1.1.9.4	SUBPART D	Subpart D - Quality Improvement
42:3.0.1.1.9.4.10.1	SECTION 422.152	422.152 Quality improvement program.
42:3.0.1.1.9.4.10.2	SECTION 422.153	422.153 Use of quality improvement organization review information.
42:3.0.1.1.9.4.10.3	SECTION 422.156	422.156 Compliance deemed on the basis of accreditation.
42:3.0.1.1.9.4.10.4	SECTION 422.157	422.157 Accreditation organizations.
42:3.0.1.1.9.4.10.5	SECTION 422.158	422.158 Procedures for approval of accreditation as a basis for deeming compliance.
42:3.0.1.1.9.4.10.6	SECTION 422.160	422.160 Basis and scope of the Medicare Advantage Quality Rating System.
42:3.0.1.1.9.4.10.7	SECTION 422.162	422.162 Medicare Advantage Quality Rating System.
42:3.0.1.1.9.4.10.8	SECTION 422.164	422.164 Adding, updating, and removing measures.
42:3.0.1.1.9.4.10.9	SECTION 422.166	422.166 Calculation of Star Ratings.
42:3.0.1.1.9.5	SUBPART E	Subpart E - Relationships With Providers
42:3.0.1.1.9.5.10.1	SECTION 422.200	422.200 Basis and scope.
42:3.0.1.1.9.5.10.2	SECTION 422.202	422.202 Participation procedures.
42:3.0.1.1.9.5.10.3	SECTION 422.204	422.204 Provider selection and credentialing.
42:3.0.1.1.9.5.10.4	SECTION 422.205	422.205 Provider antidiscrimination rules.
42:3.0.1.1.9.5.10.5	SECTION 422.206	422.206 Interference with health care professionals' advice to enrollees prohibited.
42:3.0.1.1.9.5.10.6	SECTION 422.208	422.208 Physician incentive plans: requirements and limitations.
42:3.0.1.1.9.5.10.7	SECTION 422.210	422.210 Assurances to CMS.
42:3.0.1.1.9.5.10.8	SECTION 422.212	422.212 Limitations on provider indemnification.
42:3.0.1.1.9.5.10.9	SECTION 422.214	422.214 Special rules for services furnished by noncontract providers.
42:3.0.1.1.9.5.10.10	SECTION 422.216	422.216 Special rules for MA private fee-for-service plans.
42:3.0.1.1.9.5.10.11	SECTION 422.220	422.220 Exclusion of services furnished under a private contract.
42:3.0.1.1.9.5.10.12	SECTION 422.222	422.222 Preclusion list for contracted and non-contracted individuals and entities.
42:3.0.1.1.9.5.10.13	SECTION 422.224	422.224 Payment to individuals and entities excluded by the OIG or included on the preclusion list.
42:3.0.1.1.9.6	SUBPART F	Subpart F - Submission of Bids, Premiums, and Related Information and Plan Approval
42:3.0.1.1.9.6.10.1	SECTION 422.250	422.250 Basis and scope.
42:3.0.1.1.9.6.10.2	SECTION 422.252	422.252 Terminology.
42:3.0.1.1.9.6.10.3	SECTION 422.254	422.254 Submission of bids.
42:3.0.1.1.9.6.10.4	SECTION 422.256	422.256 Review, negotiation, and approval of bids.
42:3.0.1.1.9.6.10.5	SECTION 422.258	422.258 Calculation of benchmarks.
42:3.0.1.1.9.6.10.6	SECTION 422.260	422.260 Appeals of quality bonus payment determinations.
42:3.0.1.1.9.6.10.7	SECTION 422.262	422.262 Beneficiary premiums.
42:3.0.1.1.9.6.10.8	SECTION 422.264	422.264 Calculation of savings.
42:3.0.1.1.9.6.10.9	SECTION 422.266	422.266 Beneficiary rebates.
42:3.0.1.1.9.6.10.10	SECTION 422.270	422.270 Incorrect collections of premiums and cost-sharing.
42:3.0.1.1.9.6.10.11	SECTION 422.272	422.272 Release of MA bid pricing data.
42:3.0.1.1.9.7	SUBPART G	Subpart G - Payments to Medicare Advantage Organizations
42:3.0.1.1.9.7.10.1	SECTION 422.300	422.300 Basis and scope.
42:3.0.1.1.9.7.10.2	SECTION 422.304	422.304 Monthly payments.
42:3.0.1.1.9.7.10.3	SECTION 422.306	422.306 Annual MA capitation rates.
42:3.0.1.1.9.7.10.4	SECTION 422.308	422.308 Adjustments to capitation rates, benchmarks, bids, and payments.
42:3.0.1.1.9.7.10.5	SECTION 422.310	422.310 Risk adjustment data.
42:3.0.1.1.9.7.10.6	SECTION 422.311	422.311 RADV audit dispute and appeal processes.
42:3.0.1.1.9.7.10.7	SECTION 422.312	422.312 Announcement of annual capitation rate, benchmarks, and methodology changes.
42:3.0.1.1.9.7.10.8	SECTION 422.314	422.314 Special rules for beneficiaries enrolled in MA MSA plans.
42:3.0.1.1.9.7.10.9	SECTION 422.316	422.316 Special rules for payments to Federally qualified health centers.
42:3.0.1.1.9.7.10.10	SECTION 422.318	422.318 Special rules for coverage that begins or ends during an inpatient hospital stay.
42:3.0.1.1.9.7.10.11	SECTION 422.320	422.320 Special rules for hospice care.
42:3.0.1.1.9.7.10.12	SECTION 422.322	422.322 Source of payment and effect of MA plan election on payment.
42:3.0.1.1.9.7.10.13	SECTION 422.324	422.324 Payments to MA organizations for graduate medical education costs.
42:3.0.1.1.9.7.10.14	SECTION 422.326	422.326 Reporting and returning of overpayments.
42:3.0.1.1.9.7.10.15	SECTION 422.330	422.330 CMS-identified overpayments associated with payment data submitted by MA organizations.
42:3.0.1.1.9.8	SUBPART H	Subpart H - Provider-Sponsored Organizations
42:3.0.1.1.9.8.10.1	SECTION 422.350	422.350 Basis, scope, and definitions.
42:3.0.1.1.9.8.10.2	SECTION 422.352	422.352 Basic requirements.
42:3.0.1.1.9.8.10.3	SECTION 422.354	422.354 Requirements for affiliated providers.
42:3.0.1.1.9.8.10.4	SECTION 422.356	422.356 Determining substantial financial risk and majority financial interest.
42:3.0.1.1.9.8.10.5	SECTION 422.370	422.370 Waiver of State licensure.
42:3.0.1.1.9.8.10.6	SECTION 422.372	422.372 Basis for waiver of State licensure.
42:3.0.1.1.9.8.10.7	SECTION 422.374	422.374 Waiver request and approval process.
42:3.0.1.1.9.8.10.8	SECTION 422.376	422.376 Conditions of the waiver.
42:3.0.1.1.9.8.10.9	SECTION 422.378	422.378 Relationship to State law.
42:3.0.1.1.9.8.10.10	SECTION 422.380	422.380 Solvency standards.
42:3.0.1.1.9.8.10.11	SECTION 422.382	422.382 Minimum net worth amount.
42:3.0.1.1.9.8.10.12	SECTION 422.384	422.384 Financial plan requirement.
42:3.0.1.1.9.8.10.13	SECTION 422.386	422.386 Liquidity.
42:3.0.1.1.9.8.10.14	SECTION 422.388	422.388 Deposits.
42:3.0.1.1.9.8.10.15	SECTION 422.390	422.390 Guarantees.
42:3.0.1.1.9.9	SUBPART I	Subpart I - Organization Compliance With State Law and Preemption by Federal Law
42:3.0.1.1.9.9.10.1	SECTION 422.400	422.400 State licensure requirement.
42:3.0.1.1.9.9.10.2	SECTION 422.402	422.402 Federal preemption of State law.
42:3.0.1.1.9.9.10.3	SECTION 422.404	422.404 State premium taxes prohibited.
42:3.0.1.1.9.10	SUBPART J	Subpart J - Special Rules for MA Regional Plans
42:3.0.1.1.9.10.10.1	SECTION 422.451	422.451 Moratorium on new local preferred provider organization plans.
42:3.0.1.1.9.10.10.2	SECTION 422.455	422.455 Special rules for MA Regional Plans.
42:3.0.1.1.9.10.10.3	SECTION 422.458	422.458 Risk sharing with regional MA organizations for 2006 and 2007.
42:3.0.1.1.9.11	SUBPART K	Subpart K - Application Procedures and Contracts for Medicare Advantage Organizations
42:3.0.1.1.9.11.10.1	SECTION 422.500	422.500 Scope and definitions.
42:3.0.1.1.9.11.10.2	SECTION 422.501	422.501 Application requirements.
42:3.0.1.1.9.11.10.3	SECTION 422.502	422.502 Evaluation and determination procedures.
42:3.0.1.1.9.11.10.4	SECTION 422.503	422.503 General provisions.
42:3.0.1.1.9.11.10.5	SECTION 422.504	422.504 Contract provisions.
42:3.0.1.1.9.11.10.6	SECTION 422.505	422.505 Effective date and term of contract.
42:3.0.1.1.9.11.10.7	SECTION 422.506	422.506 Nonrenewal of contract.
42:3.0.1.1.9.11.10.8	SECTION 422.508	422.508 Modification or termination of contract by mutual consent.
42:3.0.1.1.9.11.10.9	SECTION 422.510	422.510 Termination of contract by CMS.
42:3.0.1.1.9.11.10.10	SECTION 422.512	422.512 Termination of contract by the MA organization.
42:3.0.1.1.9.11.10.11	SECTION 422.514	422.514 Enrollment requirements.
42:3.0.1.1.9.11.10.12	SECTION 422.516	422.516 Validation of Part C reporting requirements.
42:3.0.1.1.9.11.10.13	SECTION 422.520	422.520 Prompt payment by MA organization.
42:3.0.1.1.9.11.10.14	SECTION 422.521	422.521 Effective date of new significant regulatory requirements.
42:3.0.1.1.9.11.10.15	SECTION 422.524	422.524 Special rules for RFB societies.
42:3.0.1.1.9.11.10.16	SECTION 422.527	422.527 Agreements with Federally qualified health centers.
42:3.0.1.1.9.11.10.17	SECTION 422.530	422.530 xxx
42:3.0.1.1.9.12	SUBPART L	Subpart L - Effect of Change of Ownership or Leasing of Facilities During Term of Contract
42:3.0.1.1.9.12.10.1	SECTION 422.550	422.550 General provisions.
42:3.0.1.1.9.12.10.2	SECTION 422.552	422.552 Novation agreement requirements.
42:3.0.1.1.9.12.10.3	SECTION 422.553	422.553 Effect of leasing of an MA organization's facilities.
42:3.0.1.1.9.13	SUBPART M	Subpart M - Grievances, Organization Determinations and Appeals
42:3.0.1.1.9.13.10	SUBJGRP 10	Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans
42:3.0.1.1.9.13.10.1	SECTION 422.560	422.560 Basis and scope.
42:3.0.1.1.9.13.10.2	SECTION 422.561	422.561 Definitions.
42:3.0.1.1.9.13.10.3	SECTION 422.562	422.562 General provisions.
42:3.0.1.1.9.13.10.4	SECTION 422.564	422.564 Grievance procedures.
42:3.0.1.1.9.13.10.5	SECTION 422.566	422.566 Organization determinations.
42:3.0.1.1.9.13.10.6	SECTION 422.568	422.568 Standard timeframes and notice requirements for organization determinations.
42:3.0.1.1.9.13.10.7	SECTION 422.570	422.570 Expediting certain organization determinations.
42:3.0.1.1.9.13.10.8	SECTION 422.572	422.572 Timeframes and notice requirements for expedited organization determinations.
42:3.0.1.1.9.13.10.9	SECTION 422.574	422.574 Parties to the organization determination.
42:3.0.1.1.9.13.10.10	SECTION 422.576	422.576 Effect of an organization determination.
42:3.0.1.1.9.13.10.11	SECTION 422.578	422.578 Right to a reconsideration.
42:3.0.1.1.9.13.10.12	SECTION 422.580	422.580 Reconsideration defined.
42:3.0.1.1.9.13.10.13	SECTION 422.582	422.582 Request for a standard reconsideration.
42:3.0.1.1.9.13.10.14	SECTION 422.584	422.584 Expediting certain reconsiderations.
42:3.0.1.1.9.13.10.15	SECTION 422.586	422.586 Opportunity to submit evidence.
42:3.0.1.1.9.13.10.16	SECTION 422.590	422.590 Timeframes and responsibility for reconsiderations.
42:3.0.1.1.9.13.10.17	SECTION 422.592	422.592 Reconsideration by an independent entity.
42:3.0.1.1.9.13.10.18	SECTION 422.594	422.594 Notice of reconsidered determination by the independent entity.
42:3.0.1.1.9.13.10.19	SECTION 422.596	422.596 Effect of a reconsidered determination.
42:3.0.1.1.9.13.10.20	SECTION 422.600	422.600 Right to a hearing.
42:3.0.1.1.9.13.10.21	SECTION 422.602	422.602 Request for an ALJ hearing.
42:3.0.1.1.9.13.10.22	SECTION 422.608	422.608 Medicare Appeals Council (Council) review.
42:3.0.1.1.9.13.10.23	SECTION 422.612	422.612 Judicial review.
42:3.0.1.1.9.13.10.24	SECTION 422.616	422.616 Reopening and revising determinations and decisions.
42:3.0.1.1.9.13.10.25	SECTION 422.618	422.618 How an MA organization must effectuate standard reconsidered determinations or decisions.
42:3.0.1.1.9.13.10.26	SECTION 422.619	422.619 How an MA organization must effectuate expedited reconsidered determinations.
42:3.0.1.1.9.13.10.27	SECTION 422.620	422.620 Notifying enrollees of hospital discharge appeal rights.
42:3.0.1.1.9.13.10.28	SECTION 422.622	422.622 Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
42:3.0.1.1.9.13.10.29	SECTION 422.624	422.624 Notifying enrollees of termination of provider services.
42:3.0.1.1.9.13.10.30	SECTION 422.626	422.626 Fast-track appeals of service terminations to independent review entities (IREs).
42:3.0.1.1.9.13.10.31	SECTION 422.629	422.629 General requirements for applicable integrated plans.
42:3.0.1.1.9.13.10.32	SECTION 422.630	422.630 Integrated grievances.
42:3.0.1.1.9.13.10.33	SECTION 422.631	422.631 Integrated organization determinations.
42:3.0.1.1.9.13.10.34	SECTION 422.632	422.632 Continuation of benefits while the applicable integrated plan reconsideration is pending.
42:3.0.1.1.9.13.10.35	SECTION 422.633	422.633 Integrated reconsideration.
42:3.0.1.1.9.13.10.36	SECTION 422.634	422.634 Effect.
42:3.0.1.1.9.14	SUBPART N	Subpart N - Medicare Contract Determinations and Appeals
42:3.0.1.1.9.14.11.1	SECTION 422.641	422.641 Contract determinations.
42:3.0.1.1.9.14.11.2	SECTION 422.644	422.644 Notice of contract determination.
42:3.0.1.1.9.14.11.3	SECTION 422.646	422.646 Effect of contract determination.
42:3.0.1.1.9.14.11.4	SECTION 422.660	422.660 Right to a hearing, burden of proof, standard of proof, and standards of review.
42:3.0.1.1.9.14.11.5	SECTION 422.662	422.662 Request for hearing.
42:3.0.1.1.9.14.11.6	SECTION 422.664	422.664 Postponement of effective date of a contract determination when a request for a hearing is filed timely.
42:3.0.1.1.9.14.11.7	SECTION 422.666	422.666 Designation of hearing officer.
42:3.0.1.1.9.14.11.8	SECTION 422.668	422.668 Disqualification of hearing officer.
42:3.0.1.1.9.14.11.9	SECTION 422.670	422.670 Time and place of hearing.
42:3.0.1.1.9.14.11.10	SECTION 422.672	422.672 Appointment of representatives.
42:3.0.1.1.9.14.11.11	SECTION 422.674	422.674 Authority of representatives.
42:3.0.1.1.9.14.11.12	SECTION 422.676	422.676 Conduct of hearing.
42:3.0.1.1.9.14.11.13	SECTION 422.678	422.678 Evidence.
42:3.0.1.1.9.14.11.14	SECTION 422.680	422.680 Witnesses.
42:3.0.1.1.9.14.11.15	SECTION 422.682	422.682 Witness lists and documents.
42:3.0.1.1.9.14.11.16	SECTION 422.684	422.684 Prehearing and summary judgment.
42:3.0.1.1.9.14.11.17	SECTION 422.686	422.686 Record of hearing.
42:3.0.1.1.9.14.11.18	SECTION 422.688	422.688 Authority of hearing officer.
42:3.0.1.1.9.14.11.19	SECTION 422.690	422.690 Notice and effect of hearing decision.
42:3.0.1.1.9.14.11.20	SECTION 422.692	422.692 Review by the Administrator.
42:3.0.1.1.9.14.11.21	SECTION 422.694	422.694 Effect of Administrator's decision.
42:3.0.1.1.9.14.11.22	SECTION 422.696	422.696 Reopening of a contract determination or decision of a hearing officer or the Administrator.
42:3.0.1.1.9.15	SUBPART O	Subpart O - Intermediate Sanctions
42:3.0.1.1.9.15.11.1	SECTION 422.750	422.750 Types of intermediate sanctions and civil money penalties.
42:3.0.1.1.9.15.11.2	SECTION 422.752	422.752 Basis for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.9.15.11.3	SECTION 422.756	422.756 Procedures for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.9.15.11.4	SECTION 422.758	422.758 Collection of civil money penalties imposed by CMS.
42:3.0.1.1.9.15.11.5	SECTION 422.760	422.760 Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
42:3.0.1.1.9.15.11.6	SECTION 422.762	422.762 Settlement of penalties.
42:3.0.1.1.9.15.11.7	SECTION 422.764	422.764 Other applicable provisions.
42:3.0.1.1.9.16	SUBPART P	Subparts P-S [Reserved]
42:3.0.1.1.9.17	SUBPART T	Subpart T - Appeal procedures for Civil Money Penalties
42:3.0.1.1.9.17.11.1	SECTION 422.1000	422.1000 Basis and scope.
42:3.0.1.1.9.17.11.2	SECTION 422.1002	422.1002 Definitions.
42:3.0.1.1.9.17.11.3	SECTION 422.1004	422.1004 Scope and applicability.
42:3.0.1.1.9.17.11.4	SECTION 422.1006	422.1006 Appeal rights.
42:3.0.1.1.9.17.11.5	SECTION 422.1008	422.1008 Appointment of representatives.
42:3.0.1.1.9.17.11.6	SECTION 422.1010	422.1010 Authority of representatives.
42:3.0.1.1.9.17.11.7	SECTION 422.1012	422.1012 Fees for services of representatives.
42:3.0.1.1.9.17.11.8	SECTION 422.1014	422.1014 Charge for transcripts.
42:3.0.1.1.9.17.11.9	SECTION 422.1016	422.1016 Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
42:3.0.1.1.9.17.11.10	SECTION 422.1018	422.1018 Notice and effect of initial determinations.
42:3.0.1.1.9.17.11.11	SECTION 422.1020	422.1020 Request for hearing.
42:3.0.1.1.9.17.11.12	SECTION 422.1022	422.1022 Parties to the hearing.
42:3.0.1.1.9.17.11.13	SECTION 422.1024	422.1024 Designation of hearing official.
42:3.0.1.1.9.17.11.14	SECTION 422.1026	422.1026 Disqualification of Administrative Law Judge.
42:3.0.1.1.9.17.11.15	SECTION 422.1028	422.1028 Prehearing conference.
42:3.0.1.1.9.17.11.16	SECTION 422.1030	422.1030 Notice of prehearing conference.
42:3.0.1.1.9.17.11.17	SECTION 422.1032	422.1032 Conduct of prehearing conference.
42:3.0.1.1.9.17.11.18	SECTION 422.1034	422.1034 Record, order, and effect of prehearing conference.
42:3.0.1.1.9.17.11.19	SECTION 422.1036	422.1036 Time and place of hearing.
42:3.0.1.1.9.17.11.20	SECTION 422.1038	422.1038 Change in time and place of hearing.
42:3.0.1.1.9.17.11.21	SECTION 422.1040	422.1040 Joint hearings.
42:3.0.1.1.9.17.11.22	SECTION 422.1042	422.1042 Hearing on new issues.
42:3.0.1.1.9.17.11.23	SECTION 422.1044	422.1044 Subpoenas.
42:3.0.1.1.9.17.11.24	SECTION 422.1046	422.1046 Conduct of hearing.
42:3.0.1.1.9.17.11.25	SECTION 422.1048	422.1048 Evidence.
42:3.0.1.1.9.17.11.26	SECTION 422.1050	422.1050 Witnesses.
42:3.0.1.1.9.17.11.27	SECTION 422.1052	422.1052 Oral and written summation.
42:3.0.1.1.9.17.11.28	SECTION 422.1054	422.1054 Record of hearing.
42:3.0.1.1.9.17.11.29	SECTION 422.1056	422.1056 Waiver of right to appear and present evidence.
42:3.0.1.1.9.17.11.30	SECTION 422.1058	422.1058 Dismissal of request for hearing.
42:3.0.1.1.9.17.11.31	SECTION 422.1060	422.1060 Dismissal for abandonment.
42:3.0.1.1.9.17.11.32	SECTION 422.1062	422.1062 Dismissal for cause.
42:3.0.1.1.9.17.11.33	SECTION 422.1064	422.1064 Notice and effect of dismissal and right to request review.
42:3.0.1.1.9.17.11.34	SECTION 422.1066	422.1066 Vacating a dismissal of request for hearing.
42:3.0.1.1.9.17.11.35	SECTION 422.1068	422.1068 Administrative Law Judge's decision.
42:3.0.1.1.9.17.11.36	SECTION 422.1070	422.1070 Removal of hearing to Departmental Appeals Board.
42:3.0.1.1.9.17.11.37	SECTION 422.1072	422.1072 Remand by the Administrative Law Judge.
42:3.0.1.1.9.17.11.38	SECTION 422.1074	422.1074 Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
42:3.0.1.1.9.17.11.39	SECTION 422.1076	422.1076 Request for Departmental Appeals Board review.
42:3.0.1.1.9.17.11.40	SECTION 422.1078	422.1078 Departmental Appeals Board action on request for review.
42:3.0.1.1.9.17.11.41	SECTION 422.1080	422.1080 Procedures before the Departmental Appeals Board on review.
42:3.0.1.1.9.17.11.42	SECTION 422.1082	422.1082 Evidence admissible on review.
42:3.0.1.1.9.17.11.43	SECTION 422.1084	422.1084 Decision or remand by the Departmental Appeals Board.
42:3.0.1.1.9.17.11.44	SECTION 422.1086	422.1086 Effect of Departmental Appeals Board Decision.
42:3.0.1.1.9.17.11.45	SECTION 422.1088	422.1088 Extension of time for seeking judicial review.
42:3.0.1.1.9.17.11.46	SECTION 422.1090	422.1090 Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
42:3.0.1.1.9.17.11.47	SECTION 422.1092	422.1092 Revision of reopened decision.
42:3.0.1.1.9.17.11.48	SECTION 422.1094	422.1094 Notice and effect of revised decision.
42:3.0.1.1.9.18	SUBPART U	Subpart U [Reserved]
42:3.0.1.1.9.19	SUBPART V	Subpart V - Medicare Advantage Communication Requirements
42:3.0.1.1.9.19.11.1	SECTION 422.2260	422.2260 Definitions.
42:3.0.1.1.9.19.11.2	SECTION 422.2261	422.2261 xxx
42:3.0.1.1.9.19.11.3	SECTION 422.2262	422.2262 Review and distribution of marketing materials.
42:3.0.1.1.9.19.11.4	SECTION 422.2263	422.2263 xxx
42:3.0.1.1.9.19.11.5	SECTION 422.2264	422.2264 Guidelines for CMS review.
42:3.0.1.1.9.19.11.6	SECTION 422.2265	422.2265 xxx
42:3.0.1.1.9.19.11.7	SECTION 422.2266	422.2266 xxx
42:3.0.1.1.9.19.11.8	SECTION 422.2267	422.2267 xxx
42:3.0.1.1.9.19.11.9	SECTION 422.2268	422.2268 Standards for MA organization communications and marketing.
42:3.0.1.1.9.19.11.10	SECTION 422.2272	422.2272 Licensing of marketing representatives and confirmation of marketing resources.
42:3.0.1.1.9.19.11.11	SECTION 422.2274	422.2274 Broker and agent requirements.
42:3.0.1.1.9.19.11.12	SECTION 422.2276	422.2276 Employer group retiree marketing.
42:3.0.1.1.9.20	SUBPART W	Subpart W [Reserved]
42:3.0.1.1.9.21	SUBPART X	Subpart X - Requirements for a Minimum Medical Loss Ratio
42:3.0.1.1.9.21.11.1	SECTION 422.2400	422.2400 Basis and scope.
42:3.0.1.1.9.21.11.2	SECTION 422.2401	422.2401 Definitions.
42:3.0.1.1.9.21.11.3	SECTION 422.2410	422.2410 General requirements.
42:3.0.1.1.9.21.11.4	SECTION 422.2420	422.2420 Calculation of the medical loss ratio.
42:3.0.1.1.9.21.11.5	SECTION 422.2430	422.2430 Activities that improve health care quality.
42:3.0.1.1.9.21.11.6	SECTION 422.2440	422.2440 Credibility adjustment.
42:3.0.1.1.9.21.11.7	SECTION 422.2450	422.2450 [Reserved]
42:3.0.1.1.9.21.11.8	SECTION 422.2460	422.2460 Reporting requirements.
42:3.0.1.1.9.21.11.9	SECTION 422.2470	422.2470 Remittance to CMS if the applicable MLR requirement is not met.
42:3.0.1.1.9.21.11.10	SECTION 422.2480	422.2480 MLR review and non-compliance.
42:3.0.1.1.9.21.11.11	SECTION 422.2490	422.2490 Release of Part C MLR data.
42:3.0.1.1.9.22	SUBPART Y	Subpart Y [Reserved]
42:3.0.1.1.9.23	SUBPART Z	Subpart Z - Part C Recovery Audit Contractor Appeals Process
42:3.0.1.1.9.23.11.1	SECTION 422.2600	422.2600 Payment appeals.
42:3.0.1.1.9.23.11.2	SECTION 422.2605	422.2605 Request for reconsideration.
42:3.0.1.1.9.23.11.3	SECTION 422.2610	422.2610 Hearing official review.
42:3.0.1.1.9.23.11.4	SECTION 422.2615	422.2615 Review by the Administrator.
42:3.0.1.1.10	PART 423	PART 423 - VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT
42:3.0.1.1.10.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.10.1.11.1	SECTION 423.1	423.1 Basis and scope.
42:3.0.1.1.10.1.11.2	SECTION 423.4	423.4 Definitions.
42:3.0.1.1.10.1.11.3	SECTION 423.6	423.6 Cost-sharing in beneficiary education and enrollment-related costs.
42:3.0.1.1.10.2	SUBPART B	Subpart B - Eligibility and Enrollment
42:3.0.1.1.10.2.11.1	SECTION 423.30	423.30 Eligibility and enrollment.
42:3.0.1.1.10.2.11.2	SECTION 423.32	423.32 Enrollment process.
42:3.0.1.1.10.2.11.3	SECTION 423.34	423.34 Enrollment of low-income subsidy eligible individuals.
42:3.0.1.1.10.2.11.4	SECTION 423.36	423.36 Disenrollment process.
42:3.0.1.1.10.2.11.5	SECTION 423.38	423.38 Enrollment periods.
42:3.0.1.1.10.2.11.6	SECTION 423.40	423.40 Effective dates.
42:3.0.1.1.10.2.11.7	SECTION 423.44	423.44 Involuntary disenrollment from Part D coverage.
42:3.0.1.1.10.2.11.8	SECTION 423.46	423.46 Late enrollment penalty.
42:3.0.1.1.10.2.11.9	SECTION 423.48	423.48 Information about Part D.
42:3.0.1.1.10.2.11.10	SECTION 423.56	423.56 Procedures to determine and document creditable status of prescription drug coverage.
42:3.0.1.1.10.3	SUBPART C	Subpart C - Benefits and Beneficiary Protections
42:3.0.1.1.10.3.11.1	SECTION 423.100	423.100 Definitions.
42:3.0.1.1.10.3.11.2	SECTION 423.104	423.104 Requirements related to qualified prescription drug coverage.
42:3.0.1.1.10.3.11.3	SECTION 423.112	423.112 Establishment of prescription drug plan service areas.
42:3.0.1.1.10.3.11.4	SECTION 423.120	423.120 Access to covered Part D drugs.
42:3.0.1.1.10.3.11.5	SECTION 423.124	423.124 Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies.
42:3.0.1.1.10.3.11.6	SECTION 423.128	423.128 Dissemination of Part D plan information.
42:3.0.1.1.10.3.11.7	SECTION 423.132	423.132 Public disclosure of pharmaceutical prices for equivalent drugs.
42:3.0.1.1.10.3.11.8	SECTION 423.136	423.136 Privacy, confidentiality, and accuracy of enrollee records.
42:3.0.1.1.10.4	SUBPART D	Subpart D - Cost Control and Quality Improvement Requirements
42:3.0.1.1.10.4.11.1	SECTION 423.150	423.150 Scope.
42:3.0.1.1.10.4.11.2	SECTION 423.153	423.153 Prescription drug plan sponsors' access to Medicare Parts A and B claims data extracts.
42:3.0.1.1.10.4.11.3	SECTION 423.154	423.154 Appropriate dispensing of prescription drugs in long-term care facilities under PDPs and MA-PD plans.
42:3.0.1.1.10.4.11.4	SECTION 423.156	423.156 Consumer satisfaction surveys.
42:3.0.1.1.10.4.11.5	SECTION 423.159	423.159 Electronic prescription drug program.
42:3.0.1.1.10.4.11.6	SECTION 423.160	423.160 Standards for electronic prescribing.
42:3.0.1.1.10.4.11.7	SECTION 423.162	423.162 Quality improvement organization activities.
42:3.0.1.1.10.4.11.8	SECTION 423.165	423.165 Compliance deemed on the basis of accreditation.
42:3.0.1.1.10.4.11.9	SECTION 423.168	423.168 Accreditation organizations.
42:3.0.1.1.10.4.11.10	SECTION 423.171	423.171 Procedures for approval of accreditation as a basis for deeming compliance.
42:3.0.1.1.10.4.11.11	SECTION 423.180	423.180 Basis and scope of the Part D Prescription Drug Plan Quality Rating System.
42:3.0.1.1.10.4.11.12	SECTION 423.182	423.182 Part D Prescription Drug Plan Quality Rating System.
42:3.0.1.1.10.4.11.13	SECTION 423.184	423.184 Adding, updating, and removing measures.
42:3.0.1.1.10.4.11.14	SECTION 423.186	423.186 Calculation of Star Ratings.
42:3.0.1.1.10.5	SUBPART E	Subpart E [Reserved]
42:3.0.1.1.10.6	SUBPART F	Subpart F - Submission of Bids and Monthly Beneficiary Premiums; Plan Approval
42:3.0.1.1.10.6.11.1	SECTION 423.251	423.251 Scope.
42:3.0.1.1.10.6.11.2	SECTION 423.258	423.258 Definitions.
42:3.0.1.1.10.6.11.3	SECTION 423.265	423.265 Submission of bids and related information.
42:3.0.1.1.10.6.11.4	SECTION 423.272	423.272 Review and negotiation of bid and approval of plans submitted by potential Part D sponsors.
42:3.0.1.1.10.6.11.5	SECTION 423.279	423.279 National average monthly bid amount.
42:3.0.1.1.10.6.11.6	SECTION 423.286	423.286 Rules regarding premiums.
42:3.0.1.1.10.6.11.7	SECTION 423.293	423.293 Collection of monthly beneficiary premium.
42:3.0.1.1.10.7	SUBPART G	Subpart G - Payments to Part D Plan Sponsors For Qualified Prescription Drug Coverage
42:3.0.1.1.10.7.11.1	SECTION 423.301	423.301 Scope.
42:3.0.1.1.10.7.11.2	SECTION 423.308	423.308 Definitions and terminology.
42:3.0.1.1.10.7.11.3	SECTION 423.315	423.315 General payment provisions.
42:3.0.1.1.10.7.11.4	SECTION 423.322	423.322 Requirement for disclosure of information.
42:3.0.1.1.10.7.11.5	SECTION 423.329	423.329 Determination of payments.
42:3.0.1.1.10.7.11.6	SECTION 423.336	423.336 Risk-sharing arrangements.
42:3.0.1.1.10.7.11.7	SECTION 423.343	423.343 Retroactive adjustments and reconciliations.
42:3.0.1.1.10.7.11.8	SECTION 423.346	423.346 Reopening.
42:3.0.1.1.10.7.11.9	SECTION 423.350	423.350 Payment appeals.
42:3.0.1.1.10.7.11.10	SECTION 423.352	423.352 CMS-identified overpayments associated with payment data submitted by Part D sponsors.
42:3.0.1.1.10.7.11.11	SECTION 423.360	423.360 Reporting and returning of overpayments.
42:3.0.1.1.10.8	SUBPART H	Subpart H [Reserved]
42:3.0.1.1.10.9	SUBPART I	Subpart I - Organization Compliance with State Law and Preemption by Federal Law
42:3.0.1.1.10.9.11.1	SECTION 423.401	423.401 General requirements for PDP sponsors.
42:3.0.1.1.10.9.11.2	SECTION 423.410	423.410 Waiver of certain requirements to expand choice.
42:3.0.1.1.10.9.11.3	SECTION 423.415	423.415 Temporary waivers for entities seeking to offer a prescription drug plan in more than one State in a region
42:3.0.1.1.10.9.11.4	SECTION 423.420	423.420 Solvency standards for non-licensed entities.
42:3.0.1.1.10.9.11.5	SECTION 423.425	423.425 Licensure does not substitute for or constitute certification.
42:3.0.1.1.10.9.11.6	SECTION 423.440	423.440 Prohibition of State imposition of premium taxes; relation to State laws.
42:3.0.1.1.10.10	SUBPART J	Subpart J - Coordination of Part D Plans With Other Prescription Drug Coverage
42:3.0.1.1.10.10.11.1	SECTION 423.452	423.452 Scope.
42:3.0.1.1.10.10.11.2	SECTION 423.454	423.454 Definitions.
42:3.0.1.1.10.10.11.3	SECTION 423.458	423.458 Application of Part D rules to certain Part D plans on and after January 1, 2006.
42:3.0.1.1.10.10.11.4	SECTION 423.462	423.462 Medicare secondary payer procedures.
42:3.0.1.1.10.10.11.5	SECTION 423.464	423.464 Coordination of benefits with other providers of prescription drug coverage.
42:3.0.1.1.10.10.11.6	SECTION 423.466	423.466 Timeframes for coordination of benefits and claims adjustments.
42:3.0.1.1.10.11	SUBPART K	Subpart K - Application Procedures and Contracts with Part D plan sponsors
42:3.0.1.1.10.11.11.1	SECTION 423.500	423.500 Scope.
42:3.0.1.1.10.11.11.2	SECTION 423.501	423.501 Definitions
42:3.0.1.1.10.11.11.3	SECTION 423.502	423.502 Application requirements.
42:3.0.1.1.10.11.11.4	SECTION 423.503	423.503 Evaluation and determination procedures for applications to be determined qualified to act as a sponsor.
42:3.0.1.1.10.11.11.5	SECTION 423.504	423.504 General provisions.
42:3.0.1.1.10.11.11.6	SECTION 423.505	423.505 Contract provisions.
42:3.0.1.1.10.11.11.7	SECTION 423.506	423.506 Effective date and term of contract.
42:3.0.1.1.10.11.11.8	SECTION 423.507	423.507 Nonrenewal of contract.
42:3.0.1.1.10.11.11.9	SECTION 423.508	423.508 Modification or termination of contract by mutual consent.
42:3.0.1.1.10.11.11.10	SECTION 423.509	423.509 Termination of contract by CMS.
42:3.0.1.1.10.11.11.11	SECTION 423.510	423.510 Termination of contract by the Part D sponsor.
42:3.0.1.1.10.11.11.12	SECTION 423.512	423.512 Minimum enrollment requirements.
42:3.0.1.1.10.11.11.13	SECTION 423.514	423.514 Validation of Part D reporting requirements.
42:3.0.1.1.10.11.11.14	SECTION 423.516	423.516 Prohibition of midyear implementation of significant new regulatory requirements.
42:3.0.1.1.10.11.11.15	SECTION 423.520	423.520 Prompt payment by Part D sponsors.
42:3.0.1.1.10.12	SUBPART L	Subpart L - Effect of Change of Ownership or Leasing of Facilities During Term of Contract
42:3.0.1.1.10.12.11.1	SECTION 423.551	423.551 General provisions.
42:3.0.1.1.10.12.11.2	SECTION 423.552	423.552 Novation agreement requirements.
42:3.0.1.1.10.12.11.3	SECTION 423.553	423.553 Effect of leasing of a PDP sponsor's facilities.
42:3.0.1.1.10.13	SUBPART M	Subpart M - Grievances, Coverage Determinations, Redeterminations, and Reconsiderations
42:3.0.1.1.10.13.11.1	SECTION 423.558	423.558 Scope.
42:3.0.1.1.10.13.11.2	SECTION 423.560	423.560 Definitions.
42:3.0.1.1.10.13.11.3	SECTION 423.562	423.562 General provisions.
42:3.0.1.1.10.13.11.4	SECTION 423.564	423.564 Grievance procedures.
42:3.0.1.1.10.13.11.5	SECTION 423.566	423.566 Coverage determinations.
42:3.0.1.1.10.13.11.6	SECTION 423.568	423.568 Standard timeframe and notice requirements for coverage determinations.
42:3.0.1.1.10.13.11.7	SECTION 423.570	423.570 Expediting certain coverage determinations.
42:3.0.1.1.10.13.11.8	SECTION 423.572	423.572 Timeframes and notice requirements for expedited coverage determinations.
42:3.0.1.1.10.13.11.9	SECTION 423.576	423.576 Effect of a coverage determination.
42:3.0.1.1.10.13.11.10	SECTION 423.578	423.578 Exceptions process.
42:3.0.1.1.10.13.11.11	SECTION 423.580	423.580 Right to a redetermination.
42:3.0.1.1.10.13.11.12	SECTION 423.582	423.582 Request for a standard redetermination.
42:3.0.1.1.10.13.11.13	SECTION 423.584	423.584 Expediting certain redeterminations.
42:3.0.1.1.10.13.11.14	SECTION 423.586	423.586 Opportunity to submit evidence.
42:3.0.1.1.10.13.11.15	SECTION 423.590	423.590 Timeframes and responsibility for making redeterminations.
42:3.0.1.1.10.13.11.16	SECTION 423.600	423.600 Reconsideration by an independent review entity (IRE).
42:3.0.1.1.10.13.11.17	SECTION 423.602	423.602 Notice of reconsideration determination by the independent review entity.
42:3.0.1.1.10.13.11.18	SECTION 423.604	423.604 Effect of a reconsideration determination.
42:3.0.1.1.10.13.11.19	SECTION 423.610-423.634	423.610-423.634 [Reserved]
42:3.0.1.1.10.13.11.20	SECTION 423.636	423.636 How a Part D plan sponsor must effectuate standard redeterminations, reconsiderations, or decisions.
42:3.0.1.1.10.13.11.21	SECTION 423.638	423.638 How a Part D plan sponsor must effectuate expedited redeterminations or reconsiderations.
42:3.0.1.1.10.14	SUBPART N	Subpart N - Medicare Contract Determinations and Appeals
42:3.0.1.1.10.14.11.1	SECTION 423.641	423.641 Contract determinations.
42:3.0.1.1.10.14.11.2	SECTION 423.642	423.642 Notice of contract determination.
42:3.0.1.1.10.14.11.3	SECTION 423.643	423.643 Effect of contract determination.
42:3.0.1.1.10.14.11.4	SECTION 423.650	423.650 Right to a hearing, burden of proof, standard of proof, and standards of review.
42:3.0.1.1.10.14.11.5	SECTION 423.651	423.651 Request for hearing.
42:3.0.1.1.10.14.11.6	SECTION 423.652	423.652 Postponement of effective date of a contract determination when a request for a hearing is filed timely.
42:3.0.1.1.10.14.11.7	SECTION 423.653	423.653 Designation of hearing officer.
42:3.0.1.1.10.14.11.8	SECTION 423.654	423.654 Disqualification of hearing officer.
42:3.0.1.1.10.14.11.9	SECTION 423.655	423.655 Time and place of hearing.
42:3.0.1.1.10.14.11.10	SECTION 423.656	423.656 Appointment of representatives.
42:3.0.1.1.10.14.11.11	SECTION 423.657	423.657 Authority of representatives.
42:3.0.1.1.10.14.11.12	SECTION 423.658	423.658 Conduct of hearing.
42:3.0.1.1.10.14.11.13	SECTION 423.659	423.659 Evidence.
42:3.0.1.1.10.14.11.14	SECTION 423.660	423.660 Witnesses.
42:3.0.1.1.10.14.11.15	SECTION 423.661	423.661 Witnesses lists and documents.
42:3.0.1.1.10.14.11.16	SECTION 423.662	423.662 Prehearing and summary judgment.
42:3.0.1.1.10.14.11.17	SECTION 423.663	423.663 Record of hearing.
42:3.0.1.1.10.14.11.18	SECTION 423.664	423.664 Authority of hearing officer.
42:3.0.1.1.10.14.11.19	SECTION 423.665	423.665 Notice and effect of hearing decision.
42:3.0.1.1.10.14.11.20	SECTION 423.666	423.666 Review by the Administrator.
42:3.0.1.1.10.14.11.21	SECTION 423.667	423.667 Effect of Administrator's decision.
42:3.0.1.1.10.14.11.22	SECTION 423.668	423.668 Reopening of a contract determination or decision of a hearing officer or the Administrator.
42:3.0.1.1.10.15	SUBPART O	Subpart O - Intermediate Sanctions
42:3.0.1.1.10.15.11.1	SECTION 423.750	423.750 Types of intermediate sanctions and civil money penalties.
42:3.0.1.1.10.15.11.2	SECTION 423.752	423.752 Basis for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.10.15.11.3	SECTION 423.756	423.756 Procedures for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.10.15.11.4	SECTION 423.758	423.758 Collection of civil money penalties imposed by CMS.
42:3.0.1.1.10.15.11.5	SECTION 423.760	423.760 Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
42:3.0.1.1.10.15.11.6	SECTION 423.762	423.762 Settlement of penalties.
42:3.0.1.1.10.15.11.7	SECTION 423.764	423.764 Other applicable provisions.
42:3.0.1.1.10.16	SUBPART P	Subpart P - Premiums and Cost-Sharing Subsidies for Low-Income Individuals
42:3.0.1.1.10.16.11.1	SECTION 423.771	423.771 Basis and scope.
42:3.0.1.1.10.16.11.2	SECTION 423.772	423.772 Definitions.
42:3.0.1.1.10.16.11.3	SECTION 423.773	423.773 Requirements for eligibility.
42:3.0.1.1.10.16.11.4	SECTION 423.774	423.774 Eligibility determinations, redeterminations, and applications.
42:3.0.1.1.10.16.11.5	SECTION 423.780	423.780 Premium subsidy.
42:3.0.1.1.10.16.11.6	SECTION 423.782	423.782 Cost-sharing subsidy.
42:3.0.1.1.10.16.11.7	SECTION 423.800	423.800 Administration of subsidy program.
42:3.0.1.1.10.17	SUBPART Q	Subpart Q - Guaranteeing Access to a Choice of Coverage (Fallback Prescription Drug Plans)
42:3.0.1.1.10.17.11.1	SECTION 423.851	423.851 Scope.
42:3.0.1.1.10.17.11.2	SECTION 423.855	423.855 Definitions.
42:3.0.1.1.10.17.11.3	SECTION 423.859	423.859 Assuring access to a choice of coverage.
42:3.0.1.1.10.17.11.4	SECTION 423.863	423.863 Submission and approval of bids.
42:3.0.1.1.10.17.11.5	SECTION 423.867	423.867 Rules regarding premiums.
42:3.0.1.1.10.17.11.6	SECTION 423.871	423.871 Contract terms and conditions.
42:3.0.1.1.10.17.11.7	SECTION 423.875	423.875 Payment to fallback plans.
42:3.0.1.1.10.18	SUBPART R	Subpart R - Payments to Sponsors of Retiree Prescription Drug Plans
42:3.0.1.1.10.18.11.1	SECTION 423.880	423.880 Basis and scope.
42:3.0.1.1.10.18.11.2	SECTION 423.882	423.882 Definitions.
42:3.0.1.1.10.18.11.3	SECTION 423.884	423.884 Requirements for qualified retiree prescription drug plans.
42:3.0.1.1.10.18.11.4	SECTION 423.886	423.886 Retiree drug subsidy amounts.
42:3.0.1.1.10.18.11.5	SECTION 423.888	423.888 Payment methods, including provision of necessary information.
42:3.0.1.1.10.18.11.6	SECTION 423.890	423.890 Appeals.
42:3.0.1.1.10.18.11.7	SECTION 423.892	423.892 Change of ownership.
42:3.0.1.1.10.18.11.8	SECTION 423.894	423.894 Construction.
42:3.0.1.1.10.19	SUBPART S	Subpart S - Special Rules for States-Eligibility Determinations for Subsidies and General Payment Provisions
42:3.0.1.1.10.19.11.1	SECTION 423.900	423.900 Basis and scope.
42:3.0.1.1.10.19.11.2	SECTION 423.902	423.902 Definitions.
42:3.0.1.1.10.19.11.3	SECTION 423.904	423.904 Eligibility determinations for low-income subsidies.
42:3.0.1.1.10.19.11.4	SECTION 423.906	423.906 General payment provisions.
42:3.0.1.1.10.19.11.5	SECTION 423.907	423.907 Treatment of territories.
42:3.0.1.1.10.19.11.6	SECTION 423.908	423.908 Phased-down State contribution to drug benefit costs assumed by Medicare.
42:3.0.1.1.10.19.11.7	SECTION 423.910	423.910 Requirements.
42:3.0.1.1.10.20	SUBPART T	Subpart T - Appeal Procedures for Civil Money Penalties
42:3.0.1.1.10.20.11.1	SECTION 423.1000	423.1000 Basis and scope.
42:3.0.1.1.10.20.11.2	SECTION 423.1002	423.1002 Definitions.
42:3.0.1.1.10.20.11.3	SECTION 423.1004	423.1004 Scope and applicability.
42:3.0.1.1.10.20.11.4	SECTION 423.1006	423.1006 Appeal rights.
42:3.0.1.1.10.20.11.5	SECTION 423.1008	423.1008 Appointment of representatives.
42:3.0.1.1.10.20.11.6	SECTION 423.1010	423.1010 Authority of representatives.
42:3.0.1.1.10.20.11.7	SECTION 423.1012	423.1012 Fees for services of representatives.
42:3.0.1.1.10.20.11.8	SECTION 423.1014	423.1014 Charge for transcripts.
42:3.0.1.1.10.20.11.9	SECTION 423.1016	423.1016 Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
42:3.0.1.1.10.20.11.10	SECTION 423.1018	423.1018 Notice and effect of initial determinations.
42:3.0.1.1.10.20.11.11	SECTION 423.1020	423.1020 Request for hearing.
42:3.0.1.1.10.20.11.12	SECTION 423.1022	423.1022 Parties to the hearing.
42:3.0.1.1.10.20.11.13	SECTION 423.1024	423.1024 Designation of hearing official.
42:3.0.1.1.10.20.11.14	SECTION 423.1026	423.1026 Disqualification of Administrative Law Judge.
42:3.0.1.1.10.20.11.15	SECTION 423.1028	423.1028 Prehearing conference.
42:3.0.1.1.10.20.11.16	SECTION 423.1030	423.1030 Notice of prehearing conference.
42:3.0.1.1.10.20.11.17	SECTION 423.1032	423.1032 Conduct of prehearing conference.
42:3.0.1.1.10.20.11.18	SECTION 423.1034	423.1034 Record, order, and effect of prehearing conference.
42:3.0.1.1.10.20.11.19	SECTION 423.1036	423.1036 Time and place of hearing.
42:3.0.1.1.10.20.11.20	SECTION 423.1038	423.1038 Change in time and place of hearing.
42:3.0.1.1.10.20.11.21	SECTION 423.1040	423.1040 Joint hearings.
42:3.0.1.1.10.20.11.22	SECTION 423.1042	423.1042 Hearing on new issues.
42:3.0.1.1.10.20.11.23	SECTION 423.1044	423.1044 Subpoenas.
42:3.0.1.1.10.20.11.24	SECTION 423.1046	423.1046 Conduct of hearing.
42:3.0.1.1.10.20.11.25	SECTION 423.1048	423.1048 Evidence.
42:3.0.1.1.10.20.11.26	SECTION 423.1050	423.1050 Witnesses.
42:3.0.1.1.10.20.11.27	SECTION 423.1052	423.1052 Oral and written summation.
42:3.0.1.1.10.20.11.28	SECTION 423.1054	423.1054 Record of hearing.
42:3.0.1.1.10.20.11.29	SECTION 423.1056	423.1056 Waiver of right to appear and present evidence.
42:3.0.1.1.10.20.11.30	SECTION 423.1058	423.1058 Dismissal of request for hearing.
42:3.0.1.1.10.20.11.31	SECTION 423.1060	423.1060 Dismissal for abandonment.
42:3.0.1.1.10.20.11.32	SECTION 423.1062	423.1062 Dismissal for cause.
42:3.0.1.1.10.20.11.33	SECTION 423.1064	423.1064 Notice and effect of dismissal and right to request review.
42:3.0.1.1.10.20.11.34	SECTION 423.1066	423.1066 Vacating a dismissal of request for hearing.
42:3.0.1.1.10.20.11.35	SECTION 423.1068	423.1068 Administrative Law Judge's decision.
42:3.0.1.1.10.20.11.36	SECTION 423.1070	423.1070 Removal of hearing to Departmental Appeals Board.
42:3.0.1.1.10.20.11.37	SECTION 423.1072	423.1072 Remand by the Administrative Law Judge.
42:3.0.1.1.10.20.11.38	SECTION 423.1074	423.1074 Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
42:3.0.1.1.10.20.11.39	SECTION 423.1076	423.1076 Request for Departmental Appeals Board review.
42:3.0.1.1.10.20.11.40	SECTION 423.1078	423.1078 Departmental Appeals Board action on request for review.
42:3.0.1.1.10.20.11.41	SECTION 423.1080	423.1080 Procedures before the Departmental Appeals Board on review.
42:3.0.1.1.10.20.11.42	SECTION 423.1082	423.1082 Evidence admissible on review.
42:3.0.1.1.10.20.11.43	SECTION 423.1084	423.1084 Decision or remand by the Departmental Appeals Board.
42:3.0.1.1.10.20.11.44	SECTION 423.1086	423.1086 Effect of Departmental Appeals Board Decision.
42:3.0.1.1.10.20.11.45	SECTION 423.1088	423.1088 Extension of time for seeking judicial review.
42:3.0.1.1.10.20.11.46	SECTION 423.1090	423.1090 Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
42:3.0.1.1.10.20.11.47	SECTION 423.1092	423.1092 Revision of reopened decision.
42:3.0.1.1.10.20.11.48	SECTION 423.1094	423.1094 Notice and effect of revised decision.
42:3.0.1.1.10.21	SUBPART U	Subpart U - Reopening, ALJ Hearings and ALJ and Attorney Adjudicator Decisions, Council Review, and Judicial Review
42:3.0.1.1.10.21.11.1	SECTION 423.1968	423.1968 Scope.
42:3.0.1.1.10.21.11.2	SECTION 423.1970-423.1976	423.1970-423.1976 [Reserved]
42:3.0.1.1.10.21.11.3	SECTION 423.1978	423.1978 Reopening determinations and decisions.
42:3.0.1.1.10.21.11.4	SECTION 423.1980	423.1980 Reopening of coverage determinations, redeterminations, reconsiderations, decisions, and reviews.
42:3.0.1.1.10.21.11.5	SECTION 423.1982	423.1982 Notice of a revised determination or decision.
42:3.0.1.1.10.21.11.6	SECTION 423.1984	423.1984 Effect of a revised determination or decision.
42:3.0.1.1.10.21.11.7	SECTION 423.1986	423.1986 Good cause for reopening.
42:3.0.1.1.10.21.11.8	SECTION 423.1990	423.1990 Expedited access to judicial review.
42:3.0.1.1.10.21.11.9	SECTION 423.2000	423.2000 Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
42:3.0.1.1.10.21.11.10	SECTION 423.2002	423.2002 Right to an ALJ hearing.
42:3.0.1.1.10.21.11.11	SECTION 423.2004	423.2004 Right to a review of IRE notice of dismissal.
42:3.0.1.1.10.21.11.12	SECTION 423.2006	423.2006 Amount in controversy required for an ALJ hearing and judicial review.
42:3.0.1.1.10.21.11.13	SECTION 423.2008	423.2008 Parties to the proceedings on a request for an ALJ hearing.
42:3.0.1.1.10.21.11.14	SECTION 423.2010	423.2010 When CMS, the IRE, or Part D plan sponsors may participate in the proceedings on a request for an ALJ hearing.
42:3.0.1.1.10.21.11.15	SECTION 423.2014	423.2014 Request for an ALJ hearing or a review of an IRE dismissal.
42:3.0.1.1.10.21.11.16	SECTION 423.2016	423.2016 Timeframes for deciding an appeal of an IRE reconsideration.
42:3.0.1.1.10.21.11.17	SECTION 423.2018	423.2018 Submitting evidence.
42:3.0.1.1.10.21.11.18	SECTION 423.2020	423.2020 Time and place for a hearing before an ALJ.
42:3.0.1.1.10.21.11.19	SECTION 423.2022	423.2022 Notice of a hearing before an ALJ.
42:3.0.1.1.10.21.11.20	SECTION 423.2024	423.2024 Objections to the issues.
42:3.0.1.1.10.21.11.21	SECTION 423.2026	423.2026 Disqualification of the ALJ or attorney adjudicator.
42:3.0.1.1.10.21.11.22	SECTION 423.2030	423.2030 ALJ hearing procedures.
42:3.0.1.1.10.21.11.23	SECTION 423.2032	423.2032 Issues before an ALJ or attorney adjudicator.
42:3.0.1.1.10.21.11.24	SECTION 423.2034	423.2034 Requesting information from the IRE.
42:3.0.1.1.10.21.11.25	SECTION 423.2036	423.2036 Description of an ALJ hearing process.
42:3.0.1.1.10.21.11.26	SECTION 423.2038	423.2038 Deciding a case without a hearing before an ALJ.
42:3.0.1.1.10.21.11.27	SECTION 423.2040	423.2040 Prehearing and posthearing conferences.
42:3.0.1.1.10.21.11.28	SECTION 423.2042	423.2042 The administrative record.
42:3.0.1.1.10.21.11.29	SECTION 423.2044	423.2044 Consolidated proceedings.
42:3.0.1.1.10.21.11.30	SECTION 423.2046	423.2046 Notice of an ALJ or attorney adjudicator decision.
42:3.0.1.1.10.21.11.31	SECTION 423.2048	423.2048 The effect of an ALJ's or attorney adjudicator's decision.
42:3.0.1.1.10.21.11.32	SECTION 423.2050	423.2050 Removal of a hearing request from OMHA to the Council.
42:3.0.1.1.10.21.11.33	SECTION 423.2052	423.2052 Dismissal of a request for a hearing before an ALJ or request for review of an IRE dismissal.
42:3.0.1.1.10.21.11.34	SECTION 423.2054	423.2054 Effect of dismissal of a request for a hearing or request for review of an IRE's dismissal.
42:3.0.1.1.10.21.11.35	SECTION 423.2056	423.2056 Remands of requests for hearing and requests for review.
42:3.0.1.1.10.21.11.36	SECTION 423.2058	423.2058 Effect of a remand.
42:3.0.1.1.10.21.11.37	SECTION 423.2062	423.2062 Applicability of policies not binding on the ALJ and Council.
42:3.0.1.1.10.21.11.38	SECTION 423.2063	423.2063 Applicability of laws, regulations, CMS Rulings, and precedential decisions.
42:3.0.1.1.10.21.11.39	SECTION 423.2100	423.2100 Medicare Appeals Council review: general.
42:3.0.1.1.10.21.11.40	SECTION 423.2102	423.2102 Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
42:3.0.1.1.10.21.11.41	SECTION 423.2106	423.2106 Where a request for review may be filed.
42:3.0.1.1.10.21.11.42	SECTION 423.2108	423.2108 Council Actions when request for review is filed.
42:3.0.1.1.10.21.11.43	SECTION 423.2110	423.2110 Council reviews on its own motion.
42:3.0.1.1.10.21.11.44	SECTION 423.2112	423.2112 Content of request for review.
42:3.0.1.1.10.21.11.45	SECTION 423.2114	423.2114 Dismissal of request for review.
42:3.0.1.1.10.21.11.46	SECTION 423.2116	423.2116 Effect of dismissal of request for Council review or request for hearing.
42:3.0.1.1.10.21.11.47	SECTION 423.2118	423.2118 Obtaining evidence from the Council.
42:3.0.1.1.10.21.11.48	SECTION 423.2120	423.2120 Filing briefs with the Council.
42:3.0.1.1.10.21.11.49	SECTION 423.2122	423.2122 What evidence may be submitted to the Council.
42:3.0.1.1.10.21.11.50	SECTION 423.2124	423.2124 Oral argument.
42:3.0.1.1.10.21.11.51	SECTION 423.2126	423.2126 Case remanded by the Council.
42:3.0.1.1.10.21.11.52	SECTION 423.2128	423.2128 Action of the Council.
42:3.0.1.1.10.21.11.53	SECTION 423.2130	423.2130 Effect of the Council's decision.
42:3.0.1.1.10.21.11.54	SECTION 423.2134	423.2134 Extension of time to file action in Federal District Court.
42:3.0.1.1.10.21.11.55	SECTION 423.2136	423.2136 Judicial review.
42:3.0.1.1.10.21.11.56	SECTION 423.2138	423.2138 Case remanded by a Federal District Court.
42:3.0.1.1.10.21.11.57	SECTION 423.2140	423.2140 Council Review of ALJ or attorney adjudicator decision in a case remanded by a Federal District Court.
42:3.0.1.1.10.22	SUBPART V	Subpart V - Part D Communication Requirements
42:3.0.1.1.10.22.11.1	SECTION 423.2260	423.2260 Definitions.
42:3.0.1.1.10.22.11.2	SECTION 423.2261	423.2261 xxx
42:3.0.1.1.10.22.11.3	SECTION 423.2262	423.2262 Review and distribution of marketing materials.
42:3.0.1.1.10.22.11.4	SECTION 423.2263	423.2263 xxx
42:3.0.1.1.10.22.11.5	SECTION 423.2264	423.2264 Guidelines for CMS review.
42:3.0.1.1.10.22.11.6	SECTION 423.2265	423.2265 xxx
42:3.0.1.1.10.22.11.7	SECTION 423.2266	423.2266 xxx
42:3.0.1.1.10.22.11.8	SECTION 423.2267	423.2267 xxx
42:3.0.1.1.10.22.11.9	SECTION 423.2268	423.2268 Standards for Part D Sponsor communications and marketing.
42:3.0.1.1.10.22.11.10	SECTION 423.2272	423.2272 Licensing of marketing representatives and confirmation of marketing resources.
42:3.0.1.1.10.22.11.11	SECTION 423.2274	423.2274 Broker and agent requirements.
42:3.0.1.1.10.22.11.12	SECTION 423.2276	423.2276 Employer group retiree marketing.
42:3.0.1.1.10.23	SUBPART W	Subpart W - Medicare Coverage Gap Discount Program
42:3.0.1.1.10.23.11.1	SECTION 423.2300	423.2300 Scope.
42:3.0.1.1.10.23.11.2	SECTION 423.2305	423.2305 Definitions.
42:3.0.1.1.10.23.11.3	SECTION 423.2310	423.2310 Condition for coverage of drugs under Part D.
42:3.0.1.1.10.23.11.4	SECTION 423.2315	423.2315 Medicare Coverage Gap Discount Program Agreement.
42:3.0.1.1.10.23.11.5	SECTION 423.2320	423.2320 Payment processes for Part D sponsors.
42:3.0.1.1.10.23.11.6	SECTION 423.2325	423.2325 Provision of applicable discounts.
42:3.0.1.1.10.23.11.7	SECTION 423.2330	423.2330 Manufacturer discount payment audit and dispute resolution.
42:3.0.1.1.10.23.11.8	SECTION 423.2335	423.2335 Beneficiary dispute resolution.
42:3.0.1.1.10.23.11.9	SECTION 423.2340	423.2340 Compliance monitoring and civil money penalties.
42:3.0.1.1.10.23.11.10	SECTION 423.2345	423.2345 Termination of Discount Program Agreement.
42:3.0.1.1.10.24	SUBPART X	Subpart X - Requirements for a Minimum Medical Loss Ratio
42:3.0.1.1.10.24.11.1	SECTION 423.2400	423.2400 Basis and scope.
42:3.0.1.1.10.24.11.2	SECTION 423.2401	423.2401 Definitions.
42:3.0.1.1.10.24.11.3	SECTION 423.2410	423.2410 General requirements.
42:3.0.1.1.10.24.11.4	SECTION 423.2420	423.2420 Calculation of medical loss ratio.
42:3.0.1.1.10.24.11.5	SECTION 423.2430	423.2430 Activities that improve health care quality.
42:3.0.1.1.10.24.11.6	SECTION 423.2440	423.2440 Credibility adjustment.
42:3.0.1.1.10.24.11.7	SECTION 423.2450	423.2450 [Reserved]
42:3.0.1.1.10.24.11.8	SECTION 423.2460	423.2460 Reporting requirements.
42:3.0.1.1.10.24.11.9	SECTION 423.2470	423.2470 Remittance to CMS if the applicable MLR requirement is not met.
42:3.0.1.1.10.24.11.10	SECTION 423.2480	423.2480 MLR review and non-compliance.
42:3.0.1.1.10.24.11.11	SECTION 423.2490	423.2490 Release of Part D MLR data.
42:3.0.1.1.10.25	SUBPART Y	Subpart Y [Reserved]
42:3.0.1.1.10.26	SUBPART Z	Subpart Z - Recovery Audit Contractor Part C Appeals Process
42:3.0.1.1.10.26.11.1	SECTION 423.2600	423.2600 Payment appeals.
42:3.0.1.1.10.26.11.2	SECTION 423.2605	423.2605 Request for reconsideration.
42:3.0.1.1.10.26.11.3	SECTION 423.2610	423.2610 Hearing official review.
42:3.0.1.1.10.26.11.4	SECTION 423.2615	423.2615 Review by the Administrator.
42:3.0.1.1.11	PART 424	PART 424 - CONDITIONS FOR MEDICARE PAYMENT
42:3.0.1.1.11.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.11.1.11.1	SECTION 424.1	424.1 Basis and scope.
42:3.0.1.1.11.1.11.2	SECTION 424.3	424.3 Definitions.
42:3.0.1.1.11.1.11.3	SECTION 424.5	424.5 Basic conditions.
42:3.0.1.1.11.1.11.4	SECTION 424.7	424.7 General limitations.
42:3.0.1.1.11.2	SUBPART B	Subpart B - Certification and Plan Requirements
42:3.0.1.1.11.2.11.1	SECTION 424.10	424.10 Purpose and scope.
42:3.0.1.1.11.2.11.2	SECTION 424.11	424.11 General procedures.
42:3.0.1.1.11.2.11.3	SECTION 424.13	424.13 Requirements for inpatient services of hospitals other than inpatient psychiatric facilities.
42:3.0.1.1.11.2.11.4	SECTION 424.14	424.14 Requirements for inpatient services of inpatient psychiatric facilities.
42:3.0.1.1.11.2.11.5	SECTION 424.15	424.15 Requirements for inpatient CAH services.
42:3.0.1.1.11.2.11.6	SECTION 424.16	424.16 Timing of certification for individual admitted to a hospital before entitlement to Medicare benefits.
42:3.0.1.1.11.2.11.7	SECTION 424.20	424.20 Requirements for posthospital SNF care.
42:3.0.1.1.11.2.11.8	SECTION 424.22	424.22 Requirements for home health services.
42:3.0.1.1.11.2.11.9	SECTION 424.24	424.24 Requirements for medical and other health services furnished by providers under Medicare Part B.
42:3.0.1.1.11.2.11.10	SECTION 424.27	424.27 Requirements for comprehensive outpatient rehabilitation facility (CORF) services.
42:3.0.1.1.11.3	SUBPART C	Subpart C - Claims for Payment
42:3.0.1.1.11.3.11.1	SECTION 424.30	424.30 Scope.
42:3.0.1.1.11.3.11.2	SECTION 424.32	424.32 Basic requirements for all claims.
42:3.0.1.1.11.3.11.3	SECTION 424.33	424.33 Additional requirements: Claims for services of providers and claims by suppliers and nonparticipating hospitals.
42:3.0.1.1.11.3.11.4	SECTION 424.34	424.34 Additional requirements: Beneficiary's claim for direct payment.
42:3.0.1.1.11.3.11.5	SECTION 424.36	424.36 Signature requirements.
42:3.0.1.1.11.3.11.6	SECTION 424.37	424.37 Evidence of authority to sign on behalf of the beneficiary.
42:3.0.1.1.11.3.11.7	SECTION 424.40	424.40 Request for payment effective for more than one claim.
42:3.0.1.1.11.3.11.8	SECTION 424.44	424.44 Time limits for filing claims.
42:3.0.1.1.11.4	SUBPART D	Subpart D - To Whom Payment Is Ordinarily Made
42:3.0.1.1.11.4.11.1	SECTION 424.50	424.50 Scope.
42:3.0.1.1.11.4.11.2	SECTION 424.51	424.51 Payment to the provider.
42:3.0.1.1.11.4.11.3	SECTION 424.52	424.52 Payment to a nonparticipating hospital.
42:3.0.1.1.11.4.11.4	SECTION 424.53	424.53 Payment to the beneficiary.
42:3.0.1.1.11.4.11.5	SECTION 424.54	424.54 Payment to the beneficiary's legal guardian or representative payee.
42:3.0.1.1.11.4.11.6	SECTION 424.55	424.55 Payment to the supplier.
42:3.0.1.1.11.4.11.7	SECTION 424.56	424.56 Payment to a beneficiary and to a supplier.
42:3.0.1.1.11.4.11.8	SECTION 424.57	424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.
42:3.0.1.1.11.4.11.9	SECTION 424.58	424.58 Accreditation.
42:3.0.1.1.11.5	SUBPART E	Subpart E - To Whom Payment is Made in Special Situations
42:3.0.1.1.11.5.11.1	SECTION 424.60	424.60 Scope.
42:3.0.1.1.11.5.11.2	SECTION 424.62	424.62 Payment after beneficiary's death: Bill has been paid.
42:3.0.1.1.11.5.11.3	SECTION 424.64	424.64 Payment after beneficiary's death: Bill has not been paid.
42:3.0.1.1.11.5.11.4	SECTION 424.66	424.66 Payment to entities that provide coverage complementary to Medicare Part B.
42:3.0.1.1.11.5.11.5	SECTION 424.67	424.67 Enrollment requirements for opioid treatment programs (OTP).
42:3.0.1.1.11.5.11.6	SECTION 424.68	424.68 Enrollment requirements for home infusion therapy suppliers.
42:3.0.1.1.11.6	SUBPART F	Subpart F - Limitations on Assignment and Reassignment of Claims
42:3.0.1.1.11.6.11.1	SECTION 424.70	424.70 Basis and scope.
42:3.0.1.1.11.6.11.2	SECTION 424.71	424.71 Definitions.
42:3.0.1.1.11.6.11.3	SECTION 424.73	424.73 Prohibition of assignment of claims by providers.
42:3.0.1.1.11.6.11.4	SECTION 424.74	424.74 Termination of provider agreement.
42:3.0.1.1.11.6.11.5	SECTION 424.80	424.80 Prohibition of reassignment of claims by suppliers.
42:3.0.1.1.11.6.11.6	SECTION 424.82	424.82 Revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.11.7	SECTION 424.83	424.83 Hearings on revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.11.8	SECTION 424.84	424.84 Final determination on revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.11.9	SECTION 424.86	424.86 Prohibition of assignment of claims by beneficiaries.
42:3.0.1.1.11.6.11.10	SECTION 424.90	424.90 Court ordered assignments: Conditions and limitations.
42:3.0.1.1.11.7	SUBPART G	Subpart G - Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital
42:3.0.1.1.11.7.11.1	SECTION 424.100	424.100 Scope.
42:3.0.1.1.11.7.11.2	SECTION 424.101	424.101 Definitions.
42:3.0.1.1.11.7.11.3	SECTION 424.102	424.102 Situations that do not constitute an emergency.
42:3.0.1.1.11.7.11.4	SECTION 424.103	424.103 Conditions for payment for emergency services.
42:3.0.1.1.11.7.11.5	SECTION 424.104	424.104 Election to claim payment for emergency services furnished during a calendar year.
42:3.0.1.1.11.7.11.6	SECTION 424.106	424.106 Criteria for determining whether the hospital was the most accessible.
42:3.0.1.1.11.7.11.7	SECTION 424.108	424.108 Payment to a hospital.
42:3.0.1.1.11.7.11.8	SECTION 424.109	424.109 Payment to the beneficiary.
42:3.0.1.1.11.8	SUBPART H	Subpart H - Special Conditions: Services Furnished in a Foreign Country
42:3.0.1.1.11.8.11.1	SECTION 424.120	424.120 Scope.
42:3.0.1.1.11.8.11.2	SECTION 424.121	424.121 Scope of payments.
42:3.0.1.1.11.8.11.3	SECTION 424.122	424.122 Conditions for payment for emergency inpatient hospital services.
42:3.0.1.1.11.8.11.4	SECTION 424.123	424.123 Conditions for payment for nonemergency inpatient services furnished by a hospital closer to the individual's residence.
42:3.0.1.1.11.8.11.5	SECTION 424.124	424.124 Conditions for payment for physician services and ambulance services.
42:3.0.1.1.11.8.11.6	SECTION 424.126	424.126 Payment to the hospital.
42:3.0.1.1.11.8.11.7	SECTION 424.127	424.127 Payment to the beneficiary.
42:3.0.1.1.11.9	SUBPART I	Subpart I - Requirements for Medicare Diabetes Prevention Program Suppliers and Beneficiary Engagement Incentives Under the Medicare Diabetes Prevention Program Expanded Model
42:3.0.1.1.11.9.11.1	SECTION 424.200	424.200 Scope.
42:3.0.1.1.11.9.11.2	SECTION 424.205	424.205 Requirements for Medicare Diabetes Prevention Program suppliers.
42:3.0.1.1.11.9.11.3	SECTION 424.210	424.210 Beneficiary engagement incentives under the Medicare Diabetes Prevention Program expanded model.
42:3.0.1.1.11.10	SUBPART J	Subparts J-L [Reserved]
42:3.0.1.1.11.11	SUBPART M	Subpart M - Replacement and Reclamation of Medicare Payments
42:3.0.1.1.11.11.11.1	SECTION 424.350	424.350 Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.
42:3.0.1.1.11.11.11.2	SECTION 424.352	424.352 Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements.
42:3.0.1.1.11.12	SUBPART N	Subparts N-O [Reserved]
42:3.0.1.1.11.13	SUBPART P	Subpart P - Requirements for Establishing and Maintaining Medicare Billing Privileges
42:3.0.1.1.11.13.11.1	SECTION 424.500	424.500 Scope.
42:3.0.1.1.11.13.11.2	SECTION 424.502	424.502 Definitions.
42:3.0.1.1.11.13.11.3	SECTION 424.505	424.505 Basic enrollment requirement.
42:3.0.1.1.11.13.11.4	SECTION 424.506	424.506 National Provider Identifier (NPI) on all enrollment applications and claims.
42:3.0.1.1.11.13.11.5	SECTION 424.507	424.507 Ordering covered items and services for Medicare beneficiaries.
42:3.0.1.1.11.13.11.6	SECTION 424.510	424.510 Requirements for enrolling in the Medicare program.
42:3.0.1.1.11.13.11.7	SECTION 424.514	424.514 Application fee.
42:3.0.1.1.11.13.11.8	SECTION 424.515	424.515 Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.
42:3.0.1.1.11.13.11.9	SECTION 424.516	424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
42:3.0.1.1.11.13.11.10	SECTION 424.517	424.517 Onsite review.
42:3.0.1.1.11.13.11.11	SECTION 424.518	424.518 Screening levels for Medicare providers and suppliers.
42:3.0.1.1.11.13.11.12	SECTION 424.519	424.519 Disclosure of affiliations.
42:3.0.1.1.11.13.11.13	SECTION 424.520	424.520 Effective date of Medicare billing privileges.
42:3.0.1.1.11.13.11.14	SECTION 424.521	424.521 Request for payment by physicians, non-physician practitioners, physician and non-physician organizations, ambulance suppliers, opioid treatment programs, and home infusion therapy suppliers.
42:3.0.1.1.11.13.11.15	SECTION 424.525	424.525 Rejection of a provider or supplier's enrollment application for Medicare enrollment.
42:3.0.1.1.11.13.11.16	SECTION 424.530	424.530 Denial of enrollment in the Medicare program.
42:3.0.1.1.11.13.11.17	SECTION 424.535	424.535 Revocation of enrollment in the Medicare program.
42:3.0.1.1.11.13.11.18	SECTION 424.540	424.540 Deactivation of Medicare billing privileges.
42:3.0.1.1.11.13.11.19	SECTION 424.545	424.545 Provider and supplier appeal rights.
42:3.0.1.1.11.13.11.20	SECTION 424.550	424.550 Prohibitions on the sale or transfer of billing privileges.
42:3.0.1.1.11.13.11.21	SECTION 424.555	424.555 Payment liability.
42:3.0.1.1.11.13.11.22	SECTION 424.565	424.565 Overpayment.
42:3.0.1.1.11.13.11.23	SECTION 424.570	424.570 Moratoria on newly enrolling Medicare providers and suppliers.
42:3.0.1.1.12	PART 425	PART 425 - MEDICARE SHARED SAVINGS PROGRAM
42:3.0.1.1.12.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.12.1.11.1	SECTION 425.10	425.10 Basis and scope.
42:3.0.1.1.12.1.11.2	SECTION 425.20	425.20 Definitions.
42:3.0.1.1.12.2	SUBPART B	Subpart B - Shared Savings Program Eligibility Requirements
42:3.0.1.1.12.2.11.1	SECTION 425.100	425.100 General.
42:3.0.1.1.12.2.11.2	SECTION 425.102	425.102 Eligible providers and suppliers.
42:3.0.1.1.12.2.11.3	SECTION 425.104	425.104 Legal entity.
42:3.0.1.1.12.2.11.4	SECTION 425.106	425.106 Shared governance.
42:3.0.1.1.12.2.11.5	SECTION 425.108	425.108 Leadership and management.
42:3.0.1.1.12.2.11.6	SECTION 425.110	425.110 Number of ACO professionals and beneficiaries.
42:3.0.1.1.12.2.11.7	SECTION 425.112	425.112 Required processes and patient-centeredness criteria.
42:3.0.1.1.12.2.11.8	SECTION 425.114	425.114 Participation in other shared savings initiatives.
42:3.0.1.1.12.2.11.9	SECTION 425.116	425.116 Agreements with ACO participants and ACO providers/suppliers.
42:3.0.1.1.12.2.11.10	SECTION 425.118	425.118 Required reporting of ACO participants and ACO providers/suppliers.
42:3.0.1.1.12.3	SUBPART C	Subpart C - Application Procedures and Participation Agreement
42:3.0.1.1.12.3.11.1	SECTION 425.200	425.200 Participation agreement with CMS.
42:3.0.1.1.12.3.11.2	SECTION 425.202	425.202 Application procedures.
42:3.0.1.1.12.3.11.3	SECTION 425.204	425.204 Content of the application.
42:3.0.1.1.12.3.11.4	SECTION 425.206	425.206 Evaluation procedures for applications.
42:3.0.1.1.12.3.11.5	SECTION 425.208	425.208 Provisions of participation agreement.
42:3.0.1.1.12.3.11.6	SECTION 425.210	425.210 Application of agreement to ACO participants, ACO providers/suppliers, and others.
42:3.0.1.1.12.3.11.7	SECTION 425.212	425.212 Changes to program requirements during the agreement period.
42:3.0.1.1.12.3.11.8	SECTION 425.214	425.214 Managing changes to the ACO during the agreement period.
42:3.0.1.1.12.3.11.9	SECTION 425.216	425.216 Actions prior to termination.
42:3.0.1.1.12.3.11.10	SECTION 425.218	425.218 Termination of the participation agreement by CMS.
42:3.0.1.1.12.3.11.11	SECTION 425.220	425.220 Termination of the participation agreement by the ACO.
42:3.0.1.1.12.3.11.12	SECTION 425.221	425.221 Close-out procedures and payment consequences of early termination.
42:3.0.1.1.12.3.11.13	SECTION 425.222	425.222 Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.
42:3.0.1.1.12.3.11.14	SECTION 425.224	425.224 Application procedures for renewing ACOs and re-entering ACOs.
42:3.0.1.1.12.3.11.15	SECTION 425.226	425.226 Annual participation elections.
42:3.0.1.1.12.4	SUBPART D	Subpart D - Program Requirements and Beneficiary Protections
42:3.0.1.1.12.4.11.1	SECTION 425.300	425.300 Compliance plan.
42:3.0.1.1.12.4.11.2	SECTION 425.302	425.302 Program requirements for data submission and certifications.
42:3.0.1.1.12.4.11.3	SECTION 425.304	425.304 Beneficiary incentives.
42:3.0.1.1.12.4.11.4	SECTION 425.305	425.305 Other program safeguards.
42:3.0.1.1.12.4.11.5	SECTION 425.306	425.306 Participant agreement and exclusivity of ACO participants.
42:3.0.1.1.12.4.11.6	SECTION 425.308	425.308 Public reporting and transparency.
42:3.0.1.1.12.4.11.7	SECTION 425.310	425.310 Marketing requirements.
42:3.0.1.1.12.4.11.8	SECTION 425.312	425.312 Beneficiary notifications.
42:3.0.1.1.12.4.11.9	SECTION 425.314	425.314 Audits and record retention.
42:3.0.1.1.12.4.11.10	SECTION 425.315	425.315 Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.
42:3.0.1.1.12.4.11.11	SECTION 425.316	425.316 Monitoring of ACOs.
42:3.0.1.1.12.5	SUBPART E	Subpart E - Assignment of Beneficiaries
42:3.0.1.1.12.5.11.1	SECTION 425.400	425.400 General.
42:3.0.1.1.12.5.11.2	SECTION 425.401	425.401 Criteria for a beneficiary to be assigned to an ACO.
42:3.0.1.1.12.5.11.3	SECTION 425.402	425.402 Basic assignment methodology.
42:3.0.1.1.12.5.11.4	SECTION 425.404	425.404 Special assignment conditions for ACOs including FQHCs and RHCs.
42:3.0.1.1.12.6	SUBPART F	Subpart F - Quality Performance Standards and Reporting
42:3.0.1.1.12.6.11.1	SECTION 425.500	425.500 Measures to assess the quality of care furnished by an ACO for performance years (or a performance period) beginning on or before January 1, 2020.
42:3.0.1.1.12.6.11.2	SECTION 425.502	425.502 Calculating the ACO quality performance score for performance years (or a performance period) beginning on or before January 1, 2020.
42:3.0.1.1.12.6.11.3	SECTION 425.504	425.504 Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.
42:3.0.1.1.12.6.11.4	SECTION 425.506	425.506 Incorporating reporting requirements related to adoption of certified electronic health record technology.
42:3.0.1.1.12.6.11.5	SECTION 425.508	425.508 Incorporating quality reporting requirements related to the Quality Payment Program.
42:3.0.1.1.12.6.11.6	SECTION 425.510	425.510 Application of the Alternative Payment Model Performance Pathway (APP) to Shared Savings Program ACOs for performance years beginning on or after January 1, 2021.
42:3.0.1.1.12.6.11.7	SECTION 425.512	425.512 Determining the ACO quality performance standard for performance years beginning on or after January 1, 2021.
42:3.0.1.1.12.7	SUBPART G	Subpart G - Shared Savings and Losses
42:3.0.1.1.12.7.11.1	SECTION 425.600	425.600 Selection of risk model.
42:3.0.1.1.12.7.11.2	SECTION 425.601	425.601 Establishing, adjusting, and updating the benchmark for agreement periods beginning on July 1, 2019, and in subsequent years.
42:3.0.1.1.12.7.11.3	SECTION 425.602	425.602 Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.
42:3.0.1.1.12.7.11.4	SECTION 425.603	425.603 Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
42:3.0.1.1.12.7.11.5	SECTION 425.604	425.604 Calculation of savings under the one-sided model.
42:3.0.1.1.12.7.11.6	SECTION 425.605	425.605 Calculation of shared savings and losses under the BASIC track.
42:3.0.1.1.12.7.11.7	SECTION 425.606	425.606 Calculation of shared savings and losses under Track 2.
42:3.0.1.1.12.7.11.8	SECTION 425.608	425.608 Determining first year performance for ACOs beginning April 1 or July 1, 2012.
42:3.0.1.1.12.7.11.9	SECTION 425.609	425.609 Determining performance for 6-month performance years during CY 2019.
42:3.0.1.1.12.7.11.10	SECTION 425.610	425.610 Calculation of shared savings and losses under the ENHANCED track.
42:3.0.1.1.12.7.11.11	SECTION 425.611	425.611 Adjustments to Shared Savings Program calculations to address the COVID-19 pandemic.
42:3.0.1.1.12.7.11.12	SECTION 425.612	425.612 Waivers of payment rules or other Medicare requirements.
42:3.0.1.1.12.7.11.13	SECTION 425.613	425.613 Telehealth services.
42:3.0.1.1.12.8	SUBPART H	Subpart H - Data Sharing With ACOs
42:3.0.1.1.12.8.11.1	SECTION 425.700	425.700 General rules.
42:3.0.1.1.12.8.11.2	SECTION 425.702	425.702 Aggregate reports.
42:3.0.1.1.12.8.11.3	SECTION 425.704	425.704 Beneficiary-identifiable claims data.
42:3.0.1.1.12.8.11.4	SECTION 425.706	425.706 Minimum necessary data.
42:3.0.1.1.12.8.11.5	SECTION 425.708	425.708 Beneficiaries may decline claims data sharing.
42:3.0.1.1.12.8.11.6	SECTION 425.710	425.710 Data use agreement.
42:3.0.1.1.12.9	SUBPART I	Subpart I - Reconsideration Review Process
42:3.0.1.1.12.9.11.1	SECTION 425.800	425.800 Preclusion of administrative and judicial review.
42:3.0.1.1.12.9.11.2	SECTION 425.802	425.802 Request for review.
42:3.0.1.1.12.9.11.3	SECTION 425.804	425.804 Reconsideration review process.
42:3.0.1.1.12.9.11.4	SECTION 425.806	425.806 On-the-record review of reconsideration official's recommendation by independent CMS official.
42:3.0.1.1.12.9.11.5	SECTION 425.808	425.808 Effect of independent CMS official's decision.
42:3.0.1.1.12.9.11.6	SECTION 425.810	425.810 Effective date of decision.
42:3.0.1.1.13	PART 426	PART 426 - REVIEW OF NATIONAL COVERAGE DETERMINATIONS AND LOCAL COVERAGE DETERMINATIONS
42:3.0.1.1.13.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.13.1.11.1	SECTION 426.100	426.100 Basis and scope.
42:3.0.1.1.13.1.11.2	SECTION 426.110	426.110 Definitions.
42:3.0.1.1.13.1.11.3	SECTION 426.120	426.120 Calculation of deadlines.
42:3.0.1.1.13.1.11.4	SECTION 426.130	426.130 Party submissions.
42:3.0.1.1.13.2	SUBPART B	Subpart B [Reserved]
42:3.0.1.1.13.3	SUBPART C	Subpart C - General Provisions for the Review of LCDs and NCDs
42:3.0.1.1.13.3.11.1	SECTION 426.300	426.300 Review of LCDs, NCDs, and deemed NCDs.
42:3.0.1.1.13.3.11.2	SECTION 426.310	426.310 LCD and NCD reviews and individual claim appeals.
42:3.0.1.1.13.3.11.3	SECTION 426.320	426.320 Who may challenge an LCD or NCD.
42:3.0.1.1.13.3.11.4	SECTION 426.325	426.325 What may be challenged.
42:3.0.1.1.13.3.11.5	SECTION 426.330	426.330 Burden of proof.
42:3.0.1.1.13.3.11.6	SECTION 426.340	426.340 Procedures for review of new evidence.
42:3.0.1.1.13.4	SUBPART D	Subpart D - Review of an LCD
42:3.0.1.1.13.4.11.1	SECTION 426.400	426.400 Procedure for filing an acceptable complaint concerning a provision (or provisions) of an LCD.
42:3.0.1.1.13.4.11.2	SECTION 426.403	426.403 Submitting new evidence once an acceptable complaint is filed.
42:3.0.1.1.13.4.11.3	SECTION 426.405	426.405 Authority of the ALJ.
42:3.0.1.1.13.4.11.4	SECTION 426.406	426.406 Ex parte contacts.
42:3.0.1.1.13.4.11.5	SECTION 426.410	426.410 Docketing and evaluating the acceptability of LCD complaints.
42:3.0.1.1.13.4.11.6	SECTION 426.415	426.415 CMS' role in the LCD review.
42:3.0.1.1.13.4.11.7	SECTION 426.416	426.416 Role of Medicare Managed Care Organizations (MCOs) and State agencies in the LCD review.
42:3.0.1.1.13.4.11.8	SECTION 426.417	426.417 Contractor's statement regarding new evidence.
42:3.0.1.1.13.4.11.9	SECTION 426.418	426.418 LCD record furnished to aggrieved party.
42:3.0.1.1.13.4.11.10	SECTION 426.419	426.419 LCD record furnished to the ALJ.
42:3.0.1.1.13.4.11.11	SECTION 426.420	426.420 Retiring or revising an LCD under review.
42:3.0.1.1.13.4.11.12	SECTION 426.423	426.423 Withdrawing a complaint regarding an LCD under review.
42:3.0.1.1.13.4.11.13	SECTION 426.425	426.425 LCD review.
42:3.0.1.1.13.4.11.14	SECTION 426.431	426.431 ALJ's review of the LCD to apply the reasonableness standard.
42:3.0.1.1.13.4.11.15	SECTION 426.432	426.432 Discovery.
42:3.0.1.1.13.4.11.16	SECTION 426.435	426.435 Subpoenas.
42:3.0.1.1.13.4.11.17	SECTION 426.440	426.440 Evidence.
42:3.0.1.1.13.4.11.18	SECTION 426.444	426.444 Dismissals for cause.
42:3.0.1.1.13.4.11.19	SECTION 426.445	426.445 Witness fees.
42:3.0.1.1.13.4.11.20	SECTION 426.446	426.446 Record of hearing.
42:3.0.1.1.13.4.11.21	SECTION 426.447	426.447 Issuance and notification of an ALJ's decision.
42:3.0.1.1.13.4.11.22	SECTION 426.450	426.450 Mandatory provisions of an ALJ's decision.
42:3.0.1.1.13.4.11.23	SECTION 426.455	426.455 Prohibited provisions of an ALJ's decision.
42:3.0.1.1.13.4.11.24	SECTION 426.457	426.457 Optional provisions of an ALJ's decision.
42:3.0.1.1.13.4.11.25	SECTION 426.458	426.458 ALJ's LCD review record.
42:3.0.1.1.13.4.11.26	SECTION 426.460	426.460 Effect of an ALJ's decision.
42:3.0.1.1.13.4.11.27	SECTION 426.462	426.462 Notice of an ALJ's decision.
42:3.0.1.1.13.4.11.28	SECTION 426.463	426.463 Future new or revised LCDs.
42:3.0.1.1.13.4.11.29	SECTION 426.465	426.465 Appealing part or all of an ALJ's decision.
42:3.0.1.1.13.4.11.30	SECTION 426.468	426.468 Decision to not appeal an ALJ's decision.
42:3.0.1.1.13.4.11.31	SECTION 426.470	426.470 Board's role in docketing and evaluating the acceptability of appeals of ALJ decisions.
42:3.0.1.1.13.4.11.32	SECTION 426.476	426.476 Board review of an ALJ's decision.
42:3.0.1.1.13.4.11.33	SECTION 426.478	426.478 Retiring or revising an LCD during the Board's review of an ALJ's decision.
42:3.0.1.1.13.4.11.34	SECTION 426.480	426.480 Withdrawing an appeal of an ALJ's decision.
42:3.0.1.1.13.4.11.35	SECTION 426.482	426.482 Issuance and notification of a Board decision.
42:3.0.1.1.13.4.11.36	SECTION 426.484	426.484 Mandatory provisions of a Board decision.
42:3.0.1.1.13.4.11.37	SECTION 426.486	426.486 Prohibited provisions of a Board decision.
42:3.0.1.1.13.4.11.38	SECTION 426.487	426.487 Board's record on appeal of an ALJ's decision.
42:3.0.1.1.13.4.11.39	SECTION 426.488	426.488 Effect of a Board decision.
42:3.0.1.1.13.4.11.40	SECTION 426.489	426.489 Board remands.
42:3.0.1.1.13.4.11.41	SECTION 426.490	426.490 Board decision.
42:3.0.1.1.13.5	SUBPART E	Subpart E - Review of an NCD
42:3.0.1.1.13.5.11.1	SECTION 426.500	426.500 Procedure for filing an acceptable complaint concerning a provision (or provisions) of an NCD.
42:3.0.1.1.13.5.11.2	SECTION 426.503	426.503 Submitting new evidence once an acceptable complaint has been filed.
42:3.0.1.1.13.5.11.3	SECTION 426.505	426.505 Authority of the Board.
42:3.0.1.1.13.5.11.4	SECTION 426.506	426.506 Ex parte contacts.
42:3.0.1.1.13.5.11.5	SECTION 426.510	426.510 Docketing and evaluating the acceptability of NCD complaints.
42:3.0.1.1.13.5.11.6	SECTION 426.513	426.513 Participation as amicus curiae.
42:3.0.1.1.13.5.11.7	SECTION 426.515	426.515 CMS' role in making the NCD record available.
42:3.0.1.1.13.5.11.8	SECTION 426.516	426.516 Role of Medicare Managed Care Organizations (MCOs) and State agencies in the NCD review process.
42:3.0.1.1.13.5.11.9	SECTION 426.517	426.517 CMS' statement regarding new evidence.
42:3.0.1.1.13.5.11.10	SECTION 426.518	426.518 NCD record furnished to the aggrieved party.
42:3.0.1.1.13.5.11.11	SECTION 426.519	426.519 NCD record furnished to the Board.
42:3.0.1.1.13.5.11.12	SECTION 426.520	426.520 Withdrawing an NCD under review or issuing a revised or reconsidered NCD.
42:3.0.1.1.13.5.11.13	SECTION 426.523	426.523 Withdrawing a complaint regarding an NCD under review.
42:3.0.1.1.13.5.11.14	SECTION 426.525	426.525 NCD review.
42:3.0.1.1.13.5.11.15	SECTION 426.531	426.531 Board's review of the NCD to apply the reasonableness standard.
42:3.0.1.1.13.5.11.16	SECTION 426.532	426.532 Discovery.
42:3.0.1.1.13.5.11.17	SECTION 426.535	426.535 Subpoenas.
42:3.0.1.1.13.5.11.18	SECTION 426.540	426.540 Evidence.
42:3.0.1.1.13.5.11.19	SECTION 426.544	426.544 Dismissals for cause.
42:3.0.1.1.13.5.11.20	SECTION 426.545	426.545 Witness fees.
42:3.0.1.1.13.5.11.21	SECTION 426.546	426.546 Record of hearing.
42:3.0.1.1.13.5.11.22	SECTION 426.547	426.547 Issuance, notification, and posting of a Board's decision.
42:3.0.1.1.13.5.11.23	SECTION 426.550	426.550 Mandatory provisions of the Board's decision.
42:3.0.1.1.13.5.11.24	SECTION 426.555	426.555 Prohibited provisions of the Board's decision.
42:3.0.1.1.13.5.11.25	SECTION 426.557	426.557 Optional provisions of the Board's decision.
42:3.0.1.1.13.5.11.26	SECTION 426.560	426.560 Effect of the Board's decision.
42:3.0.1.1.13.5.11.27	SECTION 426.562	426.562 Notice of the Board's decision.
42:3.0.1.1.13.5.11.28	SECTION 426.563	426.563 Future new or revised or reconsidered NCDs.
42:3.0.1.1.13.5.11.29	SECTION 426.565	426.565 Board's role in making an LCD or NCD review record available.
42:3.0.1.1.13.5.11.30	SECTION 426.566	426.566 Board decision.
42:3.0.1.1.13.5.11.31	SECTION 426.587	426.587 Record for appeal of a Board NCD decision.
42:3.0.1.1.14	PART 427-429	PARTS 427-429 [RESERVED]

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