Title 42

Volume 3 CHAPTER IV SUBCHAP B

Subchapter B - Medicare Program (continued)

42:3.0.1.1.1PART 414
PART 414 - PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
42:3.0.1.1.1.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.1.1.3.1SECTION 414.1
     414.1 Basis and scope.
42:3.0.1.1.1.1.3.2SECTION 414.2
     414.2 Definitions.
42:3.0.1.1.1.1.3.3SECTION 414.4
     414.4 Fee schedule areas.
42:3.0.1.1.1.1.3.4SECTION 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
42:3.0.1.1.1.2SUBPART B
Subpart B - Physicians and Other Practitioners
42:3.0.1.1.1.2.3.1SECTION 414.20
     414.20 Formula for computing fee schedule amounts.
42:3.0.1.1.1.2.3.2SECTION 414.21
     414.21 Medicare payment basis.
42:3.0.1.1.1.2.3.3SECTION 414.22
     414.22 Relative value units (RVUs).
42:3.0.1.1.1.2.3.4SECTION 414.24
     414.24 Publication of RVUs and direct PE inputs.
42:3.0.1.1.1.2.3.5SECTION 414.26
     414.26 Determining the GAF.
42:3.0.1.1.1.2.3.6SECTION 414.28
     414.28 Conversion factors.
42:3.0.1.1.1.2.3.7SECTION 414.30
     414.30 Conversion factor update.
42:3.0.1.1.1.2.3.8SECTION 414.34
     414.34 Payment for services and supplies incident to a physician's service.
42:3.0.1.1.1.2.3.9SECTION 414.36
     414.36 Payment for drugs incident to a physician's service.
42:3.0.1.1.1.2.3.10SECTION 414.39
     414.39 Special rules for payment of care plan oversight.
42:3.0.1.1.1.2.3.11SECTION 414.40
     414.40 Coding and ancillary policies.
42:3.0.1.1.1.2.3.12SECTION 414.42
     414.42 Adjustment for first 4 years of practice.
42:3.0.1.1.1.2.3.13SECTION 414.44
     414.44 Transition rules.
42:3.0.1.1.1.2.3.14SECTION 414.46
     414.46 Additional rules for payment of anesthesia services.
42:3.0.1.1.1.2.3.15SECTION 414.48
     414.48 Limits on actual charges of nonparticipating suppliers.
42:3.0.1.1.1.2.3.16SECTION 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.
42:3.0.1.1.1.2.3.17SECTION 414.52
     414.52 Payment for physician assistants' services.
42:3.0.1.1.1.2.3.18SECTION 414.54
     414.54 Payment for certified nurse-midwives' services.
42:3.0.1.1.1.2.3.19SECTION 414.56
     414.56 Payment for nurse practitioners' and clinical nurse specialists' services.
42:3.0.1.1.1.2.3.20SECTION 414.58
     414.58 Payment of charges for physician services to patients in providers.
42:3.0.1.1.1.2.3.21SECTION 414.60
     414.60 Payment for the services of CRNAs.
42:3.0.1.1.1.2.3.22SECTION 414.61
     414.61 Payment for anesthesia services furnished by a teaching CRNA.
42:3.0.1.1.1.2.3.23SECTION 414.62
     414.62 Fee schedule for clinical psychologist services.
42:3.0.1.1.1.2.3.24SECTION 414.63
     414.63 Payment for outpatient diabetes self-management training.
42:3.0.1.1.1.2.3.25SECTION 414.64
     414.64 Payment for medical nutrition therapy.
42:3.0.1.1.1.2.3.26SECTION 414.65
     414.65 Payment for telehealth services.
42:3.0.1.1.1.2.3.27SECTION 414.66
     414.66 Incentive payments for physician scarcity areas.
42:3.0.1.1.1.2.3.28SECTION 414.67
     414.67 Incentive payments for services furnished in Health Professional Shortage Areas.
42:3.0.1.1.1.2.3.29SECTION 414.68
     414.68 Imaging accreditation.
42:3.0.1.1.1.2.3.30SECTION 414.80
     414.80 Incentive payment for primary care services.
42:3.0.1.1.1.2.3.31SECTION 414.84
     414.84 Payment for MDPP services.
42:3.0.1.1.1.2.3.32SECTION 414.90
     414.90 Physician Quality Reporting System (PQRS).
42:3.0.1.1.1.2.3.33SECTION 414.92
     414.92 Electronic Prescribing Incentive Program.
42:3.0.1.1.1.2.3.34SECTION 414.94
     414.94 Appropriate use criteria for advanced diagnostic imaging services.
42:3.0.1.1.1.3SUBPART C
Subpart C - Fee Schedules for Parenteral and Enteral Nutrition (PEN) Nutrients, Equipment and Supplies, Splints, Casts, and Certain Intraocular Lenses (IOLs)
42:3.0.1.1.1.3.3.1SECTION 414.100
     414.100 Purpose.
42:3.0.1.1.1.3.3.2SECTION 414.102
     414.102 General payment rules.
42:3.0.1.1.1.3.3.3SECTION 414.104
     414.104 PEN Items and Services.
42:3.0.1.1.1.3.3.4SECTION 414.105
     414.105 Application of competitive bidding information.
42:3.0.1.1.1.3.3.5SECTION 414.106
     414.106 Splints and casts.
42:3.0.1.1.1.3.3.6SECTION 414.108
     414.108 IOLs inserted in a physician's office.
42:3.0.1.1.1.3.3.7SECTION 414.110
     414.110 Continuity of pricing when HCPCS codes are divided or combined.
42:3.0.1.1.1.3.3.8SECTION 414.112
     414.112 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
42:3.0.1.1.1.4SUBPART D
Subpart D - Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
42:3.0.1.1.1.4.3.1SECTION 414.200
     414.200 Purpose.
42:3.0.1.1.1.4.3.2SECTION 414.202
     414.202 Definitions.
42:3.0.1.1.1.4.3.3SECTION 414.210
     414.210 General payment rules.
42:3.0.1.1.1.4.3.4SECTION 414.220
     414.220 Inexpensive or routinely purchased items.
42:3.0.1.1.1.4.3.5SECTION 414.222
     414.222 Items requiring frequent and substantial servicing.
42:3.0.1.1.1.4.3.6SECTION 414.224
     414.224 Customized items.
42:3.0.1.1.1.4.3.7SECTION 414.226
     414.226 Oxygen and oxygen equipment.
42:3.0.1.1.1.4.3.8SECTION 414.228
     414.228 Prosthetic and orthotic devices.
42:3.0.1.1.1.4.3.9SECTION 414.229
     414.229 Other durable medical equipment - capped rental items.
42:3.0.1.1.1.4.3.10SECTION 414.230
     414.230 Determining a period of continuous use.
42:3.0.1.1.1.4.3.11SECTION 414.232
     414.232 Special payment rules for transcutaneous electrical nerve stimulators (TENS).
42:3.0.1.1.1.4.3.12SECTION 414.234
     414.234 Prior authorization for items frequently subject to unnecessary utilization.
42:3.0.1.1.1.4.3.13SECTION 414.236
     414.236 Continuity of pricing when HCPCS codes are divided or combined.
42:3.0.1.1.1.4.3.14SECTION 414.238
     414.238 Establishing fee schedule amounts for new HCPCS codes for items and services without a fee schedule pricing history.
42:3.0.1.1.1.5SUBPART E
Subpart E - Determination of Reasonable Charges Under the ESRD Program
42:3.0.1.1.1.5.3.1SECTION 414.300
     414.300 Scope of subpart.
42:3.0.1.1.1.5.3.2SECTION 414.310
     414.310 Determination of reasonable charges for physician services furnished to renal dialysis patients.
42:3.0.1.1.1.5.3.3SECTION 414.313
     414.313 Initial method of payment.
42:3.0.1.1.1.5.3.4SECTION 414.314
     414.314 Monthly capitation payment method.
42:3.0.1.1.1.5.3.5SECTION 414.316
     414.316 Payment for physician services to patients in training for self-dialysis and home dialysis.
42:3.0.1.1.1.5.3.6SECTION 414.320
     414.320 Determination of reasonable charges for physician renal transplantation services.
42:3.0.1.1.1.5.3.7SECTION 414.330
     414.330 Payment for home dialysis equipment, supplies, and support services.
42:3.0.1.1.1.5.3.8SECTION 414.335
     414.335 Payment for EPO furnished to a home dialysis patient for use in the home.
42:3.0.1.1.1.6SUBPART F
Subpart F - Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
42:3.0.1.1.1.6.3.1SECTION 414.400
     414.400 Purpose and basis.
42:3.0.1.1.1.6.3.2SECTION 414.402
     414.402 Definitions.
42:3.0.1.1.1.6.3.3SECTION 414.404
     414.404 Scope and applicability.
42:3.0.1.1.1.6.3.4SECTION 414.406
     414.406 Implementation of programs.
42:3.0.1.1.1.6.3.5SECTION 414.408
     414.408 Payment rules.
42:3.0.1.1.1.6.3.6SECTION 414.409
     414.409 Special payment rules.
42:3.0.1.1.1.6.3.7SECTION 414.410
     414.410 Phased-in implementation of competitive bidding programs.
42:3.0.1.1.1.6.3.8SECTION 414.411
     414.411 Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011.
42:3.0.1.1.1.6.3.9SECTION 414.412
     414.412 Submission of bids under a competitive bidding program.
42:3.0.1.1.1.6.3.10SECTION 414.414
     414.414 Conditions for awarding contracts.
42:3.0.1.1.1.6.3.11SECTION 414.416
     414.416 Determination of competitive bidding payment amounts.
42:3.0.1.1.1.6.3.12SECTION 414.418
     414.418 Opportunity for networks.
42:3.0.1.1.1.6.3.13SECTION 414.420
     414.420 Physician or treating practitioner authorization and consideration of clinical efficiency and value of items.
42:3.0.1.1.1.6.3.14SECTION 414.422
     414.422 Terms of contracts.
42:3.0.1.1.1.6.3.15SECTION 414.423
     414.423 Appeals process for breach of a DMEPOS competitive bidding program contract actions.
42:3.0.1.1.1.6.3.16SECTION 414.424
     414.424 Administrative or judicial review.
42:3.0.1.1.1.6.3.17SECTION 414.425
     414.425 Claims for damages.
42:3.0.1.1.1.6.3.18SECTION 414.426
     414.426 Adjustments to competitively bid payment amounts to reflect changes in the HCPCS.
42:3.0.1.1.1.7SUBPART G
Subpart G - Payment for Clinical Diagnostic Laboratory Tests
42:3.0.1.1.1.7.3.1SECTION 414.500
     414.500 Basis and scope.
42:3.0.1.1.1.7.3.2SECTION 414.502
     414.502 Definitions.
42:3.0.1.1.1.7.3.3SECTION 414.504
     414.504 Data reporting requirements.
42:3.0.1.1.1.7.3.4SECTION 414.506
     414.506 Procedures for public consultation for payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.5SECTION 414.507
     414.507 Payment for clinical diagnostic laboratory tests.
42:3.0.1.1.1.7.3.6SECTION 414.508
     414.508 Payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.7SECTION 414.509
     414.509 Reconsideration of basis for and amount of payment for a new clinical diagnostic laboratory test.
42:3.0.1.1.1.7.3.8SECTION 414.510
     414.510 Laboratory date of service for clinical laboratory and pathology specimens.
42:3.0.1.1.1.7.3.9SECTION 414.522
     414.522 Payment for new advanced diagnostic laboratory tests.
42:3.0.1.1.1.8SUBPART H
Subpart H - Fee Schedule for Ambulance Services
42:3.0.1.1.1.8.3.1SECTION 414.601
     414.601 Purpose.
42:3.0.1.1.1.8.3.2SECTION 414.605
     414.605 Definitions.
42:3.0.1.1.1.8.3.3SECTION 414.610
     414.610 Basis of payment.
42:3.0.1.1.1.8.3.4SECTION 414.615
     414.615 Transition to the ambulance fee schedule.
42:3.0.1.1.1.8.3.5SECTION 414.617
     414.617 Transition from regional to national ambulance fee schedule.
42:3.0.1.1.1.8.3.6SECTION 414.620
     414.620 Publication of the ambulance fee schedule.
42:3.0.1.1.1.8.3.7SECTION 414.625
     414.625 Limitation on review.
42:3.0.1.1.1.8.3.8SECTION 414.626
     414.626 Data reporting by ground ambulance organizations.
42:3.0.1.1.1.9SUBPART I
Subpart I - Payment for Drugs and Biologicals
42:3.0.1.1.1.9.3.1SECTION 414.701
     414.701 Purpose.
42:3.0.1.1.1.9.3.2SECTION 414.704
     414.704 Definitions.
42:3.0.1.1.1.9.3.3SECTION 414.707
     414.707 Basis of payment.
42:3.0.1.1.1.10SUBPART J
Subpart J - Submission of Manufacturer's Average Sales Price Data
42:3.0.1.1.1.10.3.1SECTION 414.800
     414.800 Purpose.
42:3.0.1.1.1.10.3.2SECTION 414.802
     414.802 Definitions.
42:3.0.1.1.1.10.3.3SECTION 414.804
     414.804 Basis of payment.
42:3.0.1.1.1.10.3.4SECTION 414.806
     414.806 Penalties associated with the failure to submit timely and accurate ASP data.
42:3.0.1.1.1.11SUBPART K
Subpart K - Payment for Drugs and Biologicals Under Part B
42:3.0.1.1.1.11.3.1SECTION 414.900
     414.900 Basis and scope.
42:3.0.1.1.1.11.3.2SECTION 414.902
     414.902 Definitions.
42:3.0.1.1.1.11.3.3SECTION 414.904
     414.904 Average sales price as the basis for payment.
42:3.0.1.1.1.11.3.4SECTION 414.906
     414.906 Competitive acquisition program as the basis for payment.
42:3.0.1.1.1.11.3.5SECTION 414.908
     414.908 Competitive acquisition program.
42:3.0.1.1.1.11.3.6SECTION 414.910
     414.910 Bidding process.
42:3.0.1.1.1.11.3.7SECTION 414.912
     414.912 Conflicts of interest
42:3.0.1.1.1.11.3.8SECTION 414.914
     414.914 Terms of contract.
42:3.0.1.1.1.11.3.9SECTION 414.916
     414.916 Dispute resolution for vendors and beneficiaries.
42:3.0.1.1.1.11.3.10SECTION 414.917
     414.917 Dispute resolution and process for suspension or termination of approved CAP contract and termination of physician participation under exigent circumstances.
42:3.0.1.1.1.11.3.11SECTION 414.918
     414.918 Assignment.
42:3.0.1.1.1.11.3.12SECTION 414.920
     414.920 Judicial review.
42:3.0.1.1.1.11.3.13SECTION 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.
42:3.0.1.1.1.12SUBPART L
Subpart L - Supplying and Dispensing Fees
42:3.0.1.1.1.12.3.1SECTION 414.1000
     414.1000 Purpose.
42:3.0.1.1.1.12.3.2SECTION 414.1001
     414.1001 Basis of payment.
42:3.0.1.1.1.13SUBPART M
Subpart M - Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) Services
42:3.0.1.1.1.13.3.1SECTION 414.1100
     414.1100 Basis and scope.
42:3.0.1.1.1.13.3.2SECTION 414.1105
     414.1105 Payment for Comprehensive Outpatient Rehabilitation Facility (CORF) services.
42:3.0.1.1.1.14SUBPART N
Subpart N - Value-Based Payment Modifier Under the Physician Fee Schedule
42:3.0.1.1.1.14.3.1SECTION 414.1200
     414.1200 Basis and scope.
42:3.0.1.1.1.14.3.2SECTION 414.1205
     414.1205 Definitions.
42:3.0.1.1.1.14.3.3SECTION 414.1210
     414.1210 Application of the value-based payment modifier.
42:3.0.1.1.1.14.3.4SECTION 414.1215
     414.1215 Performance and payment adjustment periods for the value-based payment modifier.
42:3.0.1.1.1.14.3.5SECTION 414.1220
     414.1220 Reporting mechanisms for the value-based payment modifier.
42:3.0.1.1.1.14.3.6SECTION 414.1225
     414.1225 Alignment of Physician Quality Reporting System quality measures and quality measures for the value-based payment modifier.
42:3.0.1.1.1.14.3.7SECTION 414.1230
     414.1230 Additional measures for groups and solo practitioners.
42:3.0.1.1.1.14.3.8SECTION 414.1235
     414.1235 Cost measures.
42:3.0.1.1.1.14.3.9SECTION 414.1240
     414.1240 Attribution for quality of care and cost measures.
42:3.0.1.1.1.14.3.10SECTION 414.1245
     414.1245 Scoring methods for the value-based payment modifier using the quality-tiering approach.
42:3.0.1.1.1.14.3.11SECTION 414.1250
     414.1250 Benchmarks for quality of care measures.
42:3.0.1.1.1.14.3.12SECTION 414.1255
     414.1255 Benchmarks for cost measures.
42:3.0.1.1.1.14.3.13SECTION 414.1260
     414.1260 Composite scores.
42:3.0.1.1.1.14.3.14SECTION 414.1265
     414.1265 Reliability of measures.
42:3.0.1.1.1.14.3.15SECTION 414.1270
     414.1270 Determination and calculation of Value-Based Payment Modifier adjustments.
42:3.0.1.1.1.14.3.16SECTION 414.1275
     414.1275 Value-based payment modifier quality-tiering scoring methodology.
42:3.0.1.1.1.14.3.17SECTION 414.1280
     414.1280 Limitation on review.
42:3.0.1.1.1.14.3.18SECTION 414.1285
     414.1285 Informal inquiry process.
42:3.0.1.1.1.15SUBPART O
Subpart O - Merit-Based Incentive Payment System and Alternative Payment Model Incentive
42:3.0.1.1.1.15.3.1SECTION 414.1300
     414.1300 Basis and scope.
42:3.0.1.1.1.15.3.2SECTION 414.1305
     414.1305 Definitions.
42:3.0.1.1.1.15.3.3SECTION 414.1310
     414.1310 Applicability.
42:3.0.1.1.1.15.3.4SECTION 414.1315
     414.1315 Virtual groups.
42:3.0.1.1.1.15.3.5SECTION 414.1320
     414.1320 MIPS performance period.
42:3.0.1.1.1.15.3.6SECTION 414.1325
     414.1325 Data submission requirements.
42:3.0.1.1.1.15.3.7SECTION 414.1330
     414.1330 Quality performance category.
42:3.0.1.1.1.15.3.8SECTION 414.1335
     414.1335 Data submission criteria for the quality performance category.
42:3.0.1.1.1.15.3.9SECTION 414.1340
     414.1340 Data completeness criteria for the quality performance category.
42:3.0.1.1.1.15.3.10SECTION 414.1350
     414.1350 Cost performance category.
42:3.0.1.1.1.15.3.11SECTION 414.1355
     414.1355 Improvement activities performance category.
42:3.0.1.1.1.15.3.12SECTION 414.1360
     414.1360 Data submission criteria for the improvement activities performance category.
42:3.0.1.1.1.15.3.13SECTION 414.1370
     414.1370 APM scoring standard under MIPS.
42:3.0.1.1.1.15.3.14SECTION 414.1375
     414.1375 Promoting Interoperability (PI) performance category.
42:3.0.1.1.1.15.3.15SECTION 414.1380
     414.1380 Scoring.
42:3.0.1.1.1.15.3.16SECTION 414.1385
     414.1385 Targeted review and review limitations.
42:3.0.1.1.1.15.3.17SECTION 414.1390
     414.1390 Data validation and auditing.
42:3.0.1.1.1.15.3.18SECTION 414.1395
     414.1395 Public reporting.
42:3.0.1.1.1.15.3.19SECTION 414.1400
     414.1400 Third party intermediaries.
42:3.0.1.1.1.15.3.20SECTION 414.1405
     414.1405 Payment.
42:3.0.1.1.1.15.3.21SECTION 414.1410
     414.1410 Advanced APM determination.
42:3.0.1.1.1.15.3.22SECTION 414.1415
     414.1415 Advanced APM criteria.
42:3.0.1.1.1.15.3.23SECTION 414.1420
     414.1420 Other payer advanced APM criteria.
42:3.0.1.1.1.15.3.24SECTION 414.1425
     414.1425 Qualifying APM participant determination: In general.
42:3.0.1.1.1.15.3.25SECTION 414.1430
     414.1430 Qualifying APM participant determination: QP and partial QP thresholds.
42:3.0.1.1.1.15.3.26SECTION 414.1435
     414.1435 Qualifying APM participant determination: Medicare option.
42:3.0.1.1.1.15.3.27SECTION 414.1440
     414.1440 Qualifying APM participant determination: All-payer combination option.
42:3.0.1.1.1.15.3.28SECTION 414.1445
     414.1445 Determination of other payer advanced APMs.
42:3.0.1.1.1.15.3.29SECTION 414.1450
     414.1450 APM incentive payment.
42:3.0.1.1.1.15.3.30SECTION 414.1455
     414.1455 Limitation on review.
42:3.0.1.1.1.15.3.31SECTION 414.1460
     414.1460 Monitoring and program integrity.
42:3.0.1.1.1.15.3.32SECTION 414.1465
     414.1465 Physician-focused payment models.
42:3.0.1.1.1.16SUBPART P
Subpart P - Home Infusion Therapy Services Payment
42:3.0.1.1.1.16.3SUBJGRP 3
  Conditions for Payment
42:3.0.1.1.1.16.3.1SECTION 414.1500
     414.1500 Basis, purpose, and scope.
42:3.0.1.1.1.16.3.2SECTION 414.1505
     414.1505 Requirement for payment.
42:3.0.1.1.1.16.3.3SECTION 414.1510
     414.1510 Beneficiary qualifications for coverage of services.
42:3.0.1.1.1.16.3.4SECTION 414.1515
     414.1515 Plan of care requirements.
42:3.0.1.1.1.16.4SUBJGRP 4
  Payment System
42:3.0.1.1.1.16.4.5SECTION 414.1550
     414.1550 Basis of payment.
42:3.0.1.1.2PART 415
PART 415 - SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN CERTAIN SETTINGS
42:3.0.1.1.2.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.2.1.5.1SECTION 415.1
     415.1 Basis and scope.
42:3.0.1.1.2.2SUBPART B
Subpart B - Fiscal Intermediary Payments to Providers for Physician Services
42:3.0.1.1.2.2.5.1SECTION 415.50
     415.50 Scope.
42:3.0.1.1.2.2.5.2SECTION 415.55
     415.55 General payment rules.
42:3.0.1.1.2.2.5.3SECTION 415.60
     415.60 Allocation of physician compensation costs.
42:3.0.1.1.2.2.5.4SECTION 415.70
     415.70 Limits on compensation for physician services in providers.
42:3.0.1.1.2.3SUBPART C
Subpart C - Part B Carrier Payments for Physician Services to Beneficiaries in Providers
42:3.0.1.1.2.3.5.1SECTION 415.100
     415.100 Scope.
42:3.0.1.1.2.3.5.2SECTION 415.102
     415.102 Conditions for fee schedule payment for physician services to beneficiaries in providers.
42:3.0.1.1.2.3.5.3SECTION 415.105
     415.105 Amounts of payment for physician services to beneficiaries in providers.
42:3.0.1.1.2.3.5.4SECTION 415.110
     415.110 Conditions for payment: Medically directed anesthesia services.
42:3.0.1.1.2.3.5.5SECTION 415.120
     415.120 Conditions for payment: Radiology services.
42:3.0.1.1.2.3.5.6SECTION 415.130
     415.130 Conditions for payment: Physician pathology services.
42:3.0.1.1.2.4SUBPART D
Subpart D - Physician Services in Teaching Settings
42:3.0.1.1.2.4.5.1SECTION 415.150
     415.150 Scope.
42:3.0.1.1.2.4.5.2SECTION 415.152
     415.152 Definitions.
42:3.0.1.1.2.4.5.3SECTION 415.160
     415.160 Election of reasonable cost payment for direct medical and surgical services of physicians in teaching hospitals: General provisions.
42:3.0.1.1.2.4.5.4SECTION 415.162
     415.162 Determining payment for physician services furnished to beneficiaries in teaching hospitals.
42:3.0.1.1.2.4.5.5SECTION 415.164
     415.164 Payment to a fund.
42:3.0.1.1.2.4.5.6SECTION 415.170
     415.170 Conditions for payment on a fee schedule basis for physician services in a teaching setting.
42:3.0.1.1.2.4.5.7SECTION 415.172
     415.172 Physician fee schedule payment for services of teaching physicians.
42:3.0.1.1.2.4.5.8SECTION 415.174
     415.174 Exception: Evaluation and management services furnished in certain centers.
42:3.0.1.1.2.4.5.9SECTION 415.176
     415.176 Renal dialysis services.
42:3.0.1.1.2.4.5.10SECTION 415.178
     415.178 Anesthesia services.
42:3.0.1.1.2.4.5.11SECTION 415.180
     415.180 Teaching setting requirements for the interpretation of diagnostic radiology and other diagnostic tests.
42:3.0.1.1.2.4.5.12SECTION 415.184
     415.184 Psychiatric services.
42:3.0.1.1.2.4.5.13SECTION 415.190
     415.190 Conditions of payment: Assistants at surgery in teaching hospitals.
42:3.0.1.1.2.5SUBPART E
Subpart E - Services of Residents
42:3.0.1.1.2.5.5.1SECTION 415.200
     415.200 Services of residents in approved GME programs.
42:3.0.1.1.2.5.5.2SECTION 415.202
     415.202 Services of residents not in approved GME programs.
42:3.0.1.1.2.5.5.3SECTION 415.204
     415.204 Services of residents in skilled nursing facilities and home health agencies.
42:3.0.1.1.2.5.5.4SECTION 415.206
     415.206 Services of residents in nonprovider settings.
42:3.0.1.1.2.5.5.5SECTION 415.208
     415.208 Services of moonlighting residents.
42:3.0.1.1.3PART 416
PART 416 - AMBULATORY SURGICAL SERVICES
42:3.0.1.1.3.1SUBPART A
Subpart A - General Provisions and Definitions
42:3.0.1.1.3.1.5.1SECTION 416.1
     416.1 Basis and scope.
42:3.0.1.1.3.1.5.2SECTION 416.2
     416.2 Definitions.
42:3.0.1.1.3.2SUBPART B
Subpart B - General Conditions and Requirements
42:3.0.1.1.3.2.5.1SECTION 416.25
     416.25 Basic requirements.
42:3.0.1.1.3.2.5.2SECTION 416.26
     416.26 Qualifying for an agreement.
42:3.0.1.1.3.2.5.3SECTION 416.30
     416.30 Terms of agreement with CMS.
42:3.0.1.1.3.2.5.4SECTION 416.35
     416.35 Termination of agreement.
42:3.0.1.1.3.3SUBPART C
Subpart C - Specific Conditions for Coverage
42:3.0.1.1.3.3.5.1SECTION 416.40
     416.40 Condition for coverage - Compliance with State licensure law.
42:3.0.1.1.3.3.5.2SECTION 416.41
     416.41 Condition for coverage - Governing body and management.
42:3.0.1.1.3.3.5.3SECTION 416.42
     416.42 Condition for coverage - Surgical services.
42:3.0.1.1.3.3.5.4SECTION 416.43
     416.43 Conditions for coverage - Quality assessment and performance improvement.
42:3.0.1.1.3.3.5.5SECTION 416.44
     416.44 Condition for coverage - Environment.
42:3.0.1.1.3.3.5.6SECTION 416.45
     416.45 Condition for coverage - Medical staff.
42:3.0.1.1.3.3.5.7SECTION 416.46
     416.46 Condition for coverage - Nursing services.
42:3.0.1.1.3.3.5.8SECTION 416.47
     416.47 Condition for coverage - Medical records.
42:3.0.1.1.3.3.5.9SECTION 416.48
     416.48 Condition for coverage - Pharmaceutical services.
42:3.0.1.1.3.3.5.10SECTION 416.49
     416.49 Condition for coverage - Laboratory and radiologic services.
42:3.0.1.1.3.3.5.11SECTION 416.50
     416.50 Condition for coverage - Patient rights.
42:3.0.1.1.3.3.5.12SECTION 416.51
     416.51 Conditions for coverage - Infection control.
42:3.0.1.1.3.3.5.13SECTION 416.52
     416.52 Conditions for coverage - Patient admission, assessment and discharge.
42:3.0.1.1.3.3.5.14SECTION 416.54
     416.54 Condition for coverage - Emergency preparedness.
42:3.0.1.1.3.4SUBPART D
Subpart D - Scope of Benefits for Services Furnished Before January 1, 2008
42:3.0.1.1.3.4.5.1SECTION 416.60
     416.60 General rules.
42:3.0.1.1.3.4.5.2SECTION 416.61
     416.61 Scope of facility services.
42:3.0.1.1.3.4.5.3SECTION 416.65
     416.65 Covered surgical procedures.
42:3.0.1.1.3.4.5.4SECTION 416.75
     416.75 Performance of listed surgical procedures on an inpatient hospital basis.
42:3.0.1.1.3.4.5.5SECTION 416.76
     416.76 Applicability.
42:3.0.1.1.3.5SUBPART E
Subpart E - Prospective Payment System for Facility Services Furnished Before January 1, 2008
42:3.0.1.1.3.5.5.1SECTION 416.120
     416.120 Basis for payment.
42:3.0.1.1.3.5.5.2SECTION 416.121
     416.121 Applicability.
42:3.0.1.1.3.5.5.3SECTION 416.125
     416.125 ASC facility services payment rate.
42:3.0.1.1.3.5.5.4SECTION 416.130
     416.130 Publication of revised payment methodologies.
42:3.0.1.1.3.5.5.5SECTION 416.140
     416.140 Surveys.
42:3.0.1.1.3.6SUBPART F
Subpart F - Coverage, Scope of ASC Services, and Prospective Payment System for ASC Services Furnished on or After January 1, 2008
42:3.0.1.1.3.6.5.1SECTION 416.160
     416.160 Basis and scope.
42:3.0.1.1.3.6.5.2SECTION 416.161
     416.161 Applicability of this subpart.
42:3.0.1.1.3.6.5.3SECTION 416.163
     416.163 General rules.
42:3.0.1.1.3.6.5.4SECTION 416.164
     416.164 Scope of ASC services.
42:3.0.1.1.3.6.5.5SECTION 416.166
     416.166 Covered surgical procedures.
42:3.0.1.1.3.6.5.6SECTION 416.167
     416.167 Basis of payment.
42:3.0.1.1.3.6.5.7SECTION 416.171
     416.171 Determination of payment rates for ASC services.
42:3.0.1.1.3.6.5.8SECTION 416.172
     416.172 Adjustments to national payment rates.
42:3.0.1.1.3.6.5.9SECTION 416.173
     416.173 Publication of revised payment methodologies and payment rates.
42:3.0.1.1.3.6.5.10SECTION 416.178
     416.178 Limitations on administrative and judicial review.
42:3.0.1.1.3.6.5.11SECTION 416.179
     416.179 Payment and coinsurance reduction for devices replaced without cost or when full or partial credit is received.
42:3.0.1.1.3.7SUBPART G
Subpart G - Adjustment in Payment Amounts for New Technology Intraocular Lenses Furnished by Ambulatory Service Centers
42:3.0.1.1.3.7.5.1SECTION 416.180
     416.180 Basis and scope.
42:3.0.1.1.3.7.5.2SECTION 416.185
     416.185 Process for establishing a new class of new technology IOLs.
42:3.0.1.1.3.7.5.3SECTION 416.190
     416.190 Request for review of payment amount.
42:3.0.1.1.3.7.5.4SECTION 416.195
     416.195 Determination of membership in new classes of new technology IOLs.
42:3.0.1.1.3.7.5.5SECTION 416.200
     416.200 Payment adjustment.
42:3.0.1.1.3.8SUBPART H
Subpart H - Requirements Under the Ambulatory Surgical Center Quality Reporting (ASCQR) Program
42:3.0.1.1.3.8.5.1SECTION 416.300
     416.300 Basis and scope of subpart.
42:3.0.1.1.3.8.5.2SECTION 416.305
     416.305 Participation and withdrawal requirements under the ASCQR Program.
42:3.0.1.1.3.8.5.3SECTION 416.310
     416.310 Data collection and submission requirements under the ASCQR Program.
42:3.0.1.1.3.8.5.4SECTION 416.315
     416.315 Public reporting of data under the ASCQR Program.
42:3.0.1.1.3.8.5.5SECTION 416.320
     416.320 Retention and removal of quality measures under the ASCQR Program.
42:3.0.1.1.3.8.5.6SECTION 416.325
     416.325 Measure maintenance under the ASCQR Program.
42:3.0.1.1.3.8.5.7SECTION 416.330
     416.330 Reconsiderations under the ASCQR Program.
42:3.0.1.1.4PART 417
PART 417 - HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
42:3.0.1.1.4.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.4.1.5.1SECTION 417.1
     417.1 Definitions.
42:3.0.1.1.4.1.5.2SECTION 417.2
     417.2 Basis and scope.
42:3.0.1.1.4.2SUBPART B
Subpart B - Qualified Health Maintenance Organizations: Services
42:3.0.1.1.4.2.5.1SECTION 417.101
     417.101 Health benefits plan: Basic health services.
42:3.0.1.1.4.2.5.2SECTION 417.102
     417.102 Health benefits plan: Supplemental health services.
42:3.0.1.1.4.2.5.3SECTION 417.103
     417.103 Providers of basic and supplemental health services.
42:3.0.1.1.4.2.5.4SECTION 417.104
     417.104 Payment for basic health services.
42:3.0.1.1.4.2.5.5SECTION 417.105
     417.105 Payment for supplemental health services.
42:3.0.1.1.4.2.5.6SECTION 417.106
     417.106 Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
42:3.0.1.1.4.3SUBPART C
Subpart C - Qualified Health Maintenance Organizations: Organization and Operation
42:3.0.1.1.4.3.5.1SECTION 417.120
     417.120 Fiscally sound operation and assumption of financial risk.
42:3.0.1.1.4.3.5.2SECTION 417.122
     417.122 Protection of enrollees.
42:3.0.1.1.4.3.5.3SECTION 417.124
     417.124 Administration and management.
42:3.0.1.1.4.3.5.4SECTION 417.126
     417.126 Recordkeeping and reporting requirements.
42:3.0.1.1.4.4SUBPART D
Subpart D - Application for Federal Qualification
42:3.0.1.1.4.4.5.1SECTION 417.140
     417.140 Scope.
42:3.0.1.1.4.4.5.2SECTION 417.142
     417.142 Requirements for qualification.
42:3.0.1.1.4.4.5.3SECTION 417.143
     417.143 Application requirements.
42:3.0.1.1.4.4.5.4SECTION 417.144
     417.144 Evaluation and determination procedures.
42:3.0.1.1.4.5SUBPART E
Subpart E - Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans
42:3.0.1.1.4.5.5.1SECTION 417.150
     417.150 Definitions.
42:3.0.1.1.4.5.5.2SECTION 417.151
     417.151 Applicability.
42:3.0.1.1.4.5.5.3SECTION 417.153
     417.153 Offer of HMO alternative.
42:3.0.1.1.4.5.5.4SECTION 417.155
     417.155 How the HMO option must be included in the health benefits plan.
42:3.0.1.1.4.5.5.5SECTION 417.156
     417.156 When the HMO must be offered to employees.
42:3.0.1.1.4.5.5.6SECTION 417.157
     417.157 Contributions for the HMO alternative.
42:3.0.1.1.4.5.5.7SECTION 417.158
     417.158 Payroll deductions.
42:3.0.1.1.4.5.5.8SECTION 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.
42:3.0.1.1.4.6SUBPART F
Subpart F - Continued Regulation of Federally Qualified Health Maintenance Organizations
42:3.0.1.1.4.6.5.1SECTION 417.160
     417.160 Applicability.
42:3.0.1.1.4.6.5.2SECTION 417.161
     417.161 Compliance with assurances.
42:3.0.1.1.4.6.5.3SECTION 417.162
     417.162 Reporting requirements.
42:3.0.1.1.4.6.5.4SECTION 417.163
     417.163 Enforcement procedures.
42:3.0.1.1.4.6.5.5SECTION 417.164
     417.164 Effect of revocation of qualification on inclusion in employee's health benefit plans.
42:3.0.1.1.4.6.5.6SECTION 417.165
     417.165 Reapplication for qualification.
42:3.0.1.1.4.6.5.7SECTION 417.166
     417.166 Waiver of assurances.
42:3.0.1.1.4.7SUBPART G
Subparts G-I [Reserved]
42:3.0.1.1.4.8SUBPART J
Subpart J - Qualifying Conditions for Medicare Contracts
42:3.0.1.1.4.8.5.1SECTION 417.400
     417.400 Basis and scope.
42:3.0.1.1.4.8.5.2SECTION 417.401
     417.401 Definitions.
42:3.0.1.1.4.8.5.3SECTION 417.402
     417.402 Effective date of initial regulations.
42:3.0.1.1.4.8.5.4SECTION 417.404
     417.404 General requirements.
42:3.0.1.1.4.8.5.5SECTION 417.406
     417.406 Application and determination.
42:3.0.1.1.4.8.5.6SECTION 417.407
     417.407 Requirements for a Competitive Medical Plan (CMP).
42:3.0.1.1.4.8.5.7SECTION 417.408
     417.408 Contract application process.
42:3.0.1.1.4.8.5.8SECTION 417.410
     417.410 Qualifying conditions: General rules.
42:3.0.1.1.4.8.5.9SECTION 417.412
     417.412 Qualifying condition: Administration and management.
42:3.0.1.1.4.8.5.10SECTION 417.413
     417.413 Qualifying condition: Operating experience and enrollment.
42:3.0.1.1.4.8.5.11SECTION 417.414
     417.414 Qualifying condition: Range of services.
42:3.0.1.1.4.8.5.12SECTION 417.416
     417.416 Qualifying condition: Furnishing of services.
42:3.0.1.1.4.8.5.13SECTION 417.418
     417.418 Qualifying condition: Quality assurance program.
42:3.0.1.1.4.9SUBPART K
Subpart K - Enrollment, Entitlement, and Disenrollment under Medicare Contract
42:3.0.1.1.4.9.5.1SECTION 417.420
     417.420 Basic rules on enrollment and entitlement.
42:3.0.1.1.4.9.5.2SECTION 417.422
     417.422 Eligibility to enroll in an HMO or CMP.
42:3.0.1.1.4.9.5.3SECTION 417.423
     417.423 Special rules: ESRD and hospice patients.
42:3.0.1.1.4.9.5.4SECTION 417.424
     417.424 Denial of enrollment.
42:3.0.1.1.4.9.5.5SECTION 417.426
     417.426 Open enrollment requirements.
42:3.0.1.1.4.9.5.6SECTION 417.427
     417.427 Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
42:3.0.1.1.4.9.5.7SECTION 417.428
     417.428 Marketing activities.
42:3.0.1.1.4.9.5.8SECTION 417.430
     417.430 Application procedures.
42:3.0.1.1.4.9.5.9SECTION 417.432
     417.432 Conversion of enrollment.
42:3.0.1.1.4.9.5.10SECTION 417.434
     417.434 Reenrollment.
42:3.0.1.1.4.9.5.11SECTION 417.436
     417.436 Rules for enrollees.
42:3.0.1.1.4.9.5.12SECTION 417.440
     417.440 Entitlement to health care services from an HMO or CMP.
42:3.0.1.1.4.9.5.13SECTION 417.442
     417.442 Risk HMO's and CMP's: Conditions for provision of additional benefits.
42:3.0.1.1.4.9.5.14SECTION 417.444
     417.444 Special rules for certain enrollees of risk HMOs and CMPs.
42:3.0.1.1.4.9.5.15SECTION 417.446
     417.446 [Reserved]
42:3.0.1.1.4.9.5.16SECTION 417.448
     417.448 Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
42:3.0.1.1.4.9.5.17SECTION 417.450
     417.450 Effective date of coverage.
42:3.0.1.1.4.9.5.18SECTION 417.452
     417.452 Liability of Medicare enrollees.
42:3.0.1.1.4.9.5.19SECTION 417.454
     417.454 Charges to Medicare enrollees.
42:3.0.1.1.4.9.5.20SECTION 417.456
     417.456 Refunds to Medicare enrollees.
42:3.0.1.1.4.9.5.21SECTION 417.458
     417.458 Recoupment of uncollected deductible and coinsurance amounts.
42:3.0.1.1.4.9.5.22SECTION 417.460
     417.460 Disenrollment of beneficiaries by an HMO or CMP.
42:3.0.1.1.4.9.5.23SECTION 417.461
     417.461 Disenrollment by the enrollee.
42:3.0.1.1.4.9.5.24SECTION 417.464
     417.464 End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
42:3.0.1.1.4.10SUBPART L
Subpart L - Medicare Contract Requirements
42:3.0.1.1.4.10.5.1SECTION 417.470
     417.470 Basis and scope.
42:3.0.1.1.4.10.5.2SECTION 417.472
     417.472 Basic contract requirements.
42:3.0.1.1.4.10.5.3SECTION 417.474
     417.474 Effective date and term of contract.
42:3.0.1.1.4.10.5.4SECTION 417.476
     417.476 Waived conditions.
42:3.0.1.1.4.10.5.5SECTION 417.478
     417.478 Requirements of other laws and regulations.
42:3.0.1.1.4.10.5.6SECTION 417.479
     417.479 Requirements for physician incentive plans.
42:3.0.1.1.4.10.5.7SECTION 417.480
     417.480 Maintenance of records: Cost HMOs and CMPs.
42:3.0.1.1.4.10.5.8SECTION 417.481
     417.481 Maintenance of records: Risk HMOs and CMPs.
42:3.0.1.1.4.10.5.9SECTION 417.482
     417.482 Access to facilities and records.
42:3.0.1.1.4.10.5.10SECTION 417.484
     417.484 Requirement applicable to related entities.
42:3.0.1.1.4.10.5.11SECTION 417.486
     417.486 Disclosure of information and confidentiality.
42:3.0.1.1.4.10.5.12SECTION 417.488
     417.488 Notice of termination and of available alternatives: Risk contract.
42:3.0.1.1.4.10.5.13SECTION 417.490
     417.490 Renewal of contract.
42:3.0.1.1.4.10.5.14SECTION 417.492
     417.492 Nonrenewal of contract.
42:3.0.1.1.4.10.5.15SECTION 417.494
     417.494 Modification or termination of contract.
42:3.0.1.1.4.10.5.16SECTION 417.500
     417.500 Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
42:3.0.1.1.4.11SUBPART M
Subpart M - Change of Ownership and Leasing of Facilities: Effect on Medicare Contract
42:3.0.1.1.4.11.5.1SECTION 417.520
     417.520 Effect on HMO and CMP contracts.
42:3.0.1.1.4.12SUBPART N
Subpart N - Medicare Payment to HMOs and CMPs: General Rules
42:3.0.1.1.4.12.5.1SECTION 417.524
     417.524 Payment to HMOs or CMPs: General.
42:3.0.1.1.4.12.5.2SECTION 417.526
     417.526 Payment for covered services.
42:3.0.1.1.4.12.5.3SECTION 417.528
     417.528 Payment when Medicare is not primary payer.
42:3.0.1.1.4.13SUBPART O
Subpart O - Medicare Payment: Cost Basis
42:3.0.1.1.4.13.5.1SECTION 417.530
     417.530 Basis and scope.
42:3.0.1.1.4.13.5.2SECTION 417.531
     417.531 Hospice care services.
42:3.0.1.1.4.13.5.3SECTION 417.532
     417.532 General considerations.
42:3.0.1.1.4.13.5.4SECTION 417.533
     417.533 Part B carrier responsibilities.
42:3.0.1.1.4.13.5.5SECTION 417.534
     417.534 Allowable costs.
42:3.0.1.1.4.13.5.6SECTION 417.536
     417.536 Cost payment principles.
42:3.0.1.1.4.13.5.7SECTION 417.538
     417.538 Enrollment and marketing costs.
42:3.0.1.1.4.13.5.8SECTION 417.540
     417.540 Enrollment costs.
42:3.0.1.1.4.13.5.9SECTION 417.542
     417.542 Reinsurance costs.
42:3.0.1.1.4.13.5.10SECTION 417.544
     417.544 Physicians' services furnished directly by the HMO or CMP.
42:3.0.1.1.4.13.5.11SECTION 417.546
     417.546 Physicians' services and other Part B supplier services furnished under arrangements.
42:3.0.1.1.4.13.5.12SECTION 417.548
     417.548 Provider services through arrangements.
42:3.0.1.1.4.13.5.13SECTION 417.550
     417.550 Special Medicare program requirements.
42:3.0.1.1.4.13.5.14SECTION 417.552
     417.552 Cost apportionment: General provisions.
42:3.0.1.1.4.13.5.15SECTION 417.554
     417.554 Apportionment: Provider services furnished directly by the HMO or CMP.
42:3.0.1.1.4.13.5.16SECTION 417.556
     417.556 Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
42:3.0.1.1.4.13.5.17SECTION 417.558
     417.558 Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
42:3.0.1.1.4.13.5.18SECTION 417.560
     417.560 Apportionment: Part B physician and supplier services.
42:3.0.1.1.4.13.5.19SECTION 417.564
     417.564 Apportionment and allocation of administrative and general costs.
42:3.0.1.1.4.13.5.20SECTION 417.566
     417.566 Other methods of allocation and apportionment.
42:3.0.1.1.4.13.5.21SECTION 417.568
     417.568 Adequate financial records, statistical data, and cost finding.
42:3.0.1.1.4.13.5.22SECTION 417.570
     417.570 Interim per capita payments.
42:3.0.1.1.4.13.5.23SECTION 417.572
     417.572 Budget and enrollment forecast and interim reports.
42:3.0.1.1.4.13.5.24SECTION 417.574
     417.574 Interim settlement.
42:3.0.1.1.4.13.5.25SECTION 417.576
     417.576 Final settlement.
42:3.0.1.1.4.14SUBPART P
Subpart P - Medicare Payment: Risk Basis
42:3.0.1.1.4.14.5.1SECTION 417.580
     417.580 Basis and scope.
42:3.0.1.1.4.14.5.2SECTION 417.582
     417.582 Definitions.
42:3.0.1.1.4.14.5.3SECTION 417.584
     417.584 Payment to HMOs or CMPs with risk contracts.
42:3.0.1.1.4.14.5.4SECTION 417.585
     417.585 Special rules: Hospice care.
42:3.0.1.1.4.14.5.5SECTION 417.588
     417.588 Computation of adjusted average per capita cost (AAPCC).
42:3.0.1.1.4.14.5.6SECTION 417.590
     417.590 Computation of the average of the per capita rates of payment.
42:3.0.1.1.4.14.5.7SECTION 417.592
     417.592 Additional benefits requirement.
42:3.0.1.1.4.14.5.8SECTION 417.594
     417.594 Computation of adjusted community rate (ACR).
42:3.0.1.1.4.14.5.9SECTION 417.596
     417.596 Establishment of a benefit stabilization fund.
42:3.0.1.1.4.14.5.10SECTION 417.597
     417.597 Withdrawal from a benefit stabilization fund.
42:3.0.1.1.4.14.5.11SECTION 417.598
     417.598 Annual enrollment reconciliation.
42:3.0.1.1.4.15SUBPART Q
Subpart Q - Beneficiary Appeals
42:3.0.1.1.4.15.5.1SECTION 417.600
     417.600 Basis and scope.
42:3.0.1.1.4.16SUBPART R
Subpart R - Medicare Contract Appeals
42:3.0.1.1.4.16.5.1SECTION 417.640
     417.640 Applicability.
42:3.0.1.1.4.17SUBPART S
Subparts S-T [Reserved]
42:3.0.1.1.4.18SUBPART U
Subpart U - Health Care Prepayment Plans
42:3.0.1.1.4.18.5.1SECTION 417.800
     417.800 Payment to HCPPs: Definitions and basic rules.
42:3.0.1.1.4.18.5.2SECTION 417.801
     417.801 Agreements between CMS and health care prepayment plans.
42:3.0.1.1.4.18.5.3SECTION 417.802
     417.802 Allowable costs.
42:3.0.1.1.4.18.5.4SECTION 417.804
     417.804 Cost apportionment.
42:3.0.1.1.4.18.5.5SECTION 417.806
     417.806 Financial records, statistical data, and cost finding.
42:3.0.1.1.4.18.5.6SECTION 417.808
     417.808 Interim per capita payments.
42:3.0.1.1.4.18.5.7SECTION 417.810
     417.810 Final settlement.
42:3.0.1.1.4.18.5.8SECTION 417.830
     417.830 Scope of regulations on beneficiary appeals.
42:3.0.1.1.4.18.5.9SECTION 417.832
     417.832 Applicability of requirements and procedures.
42:3.0.1.1.4.18.5.10SECTION 417.834
     417.834 Responsibility for establishing administrative review procedures.
42:3.0.1.1.4.18.5.11SECTION 417.836
     417.836 Written description of administrative review procedures.
42:3.0.1.1.4.18.5.12SECTION 417.838
     417.838 Organization determinations.
42:3.0.1.1.4.18.5.13SECTION 417.840
     417.840 Administrative review procedures.
42:3.0.1.1.4.19SUBPART V
Subpart V - Administration of Outstanding Loans and Loan Guarantees
42:3.0.1.1.4.19.5.1SECTION 417.910
     417.910 Applicability.
42:3.0.1.1.4.19.5.2SECTION 417.911
     417.911 Definitions.
42:3.0.1.1.4.19.5.3SECTION 417.920
     417.920 Planning and initial development.
42:3.0.1.1.4.19.5.4SECTION 417.930
     417.930 Initial costs of operation.
42:3.0.1.1.4.19.5.5SECTION 417.931
     417.931 [Reserved]
42:3.0.1.1.4.19.5.6SECTION 417.934
     417.934 Reserve requirement.
42:3.0.1.1.4.19.5.7SECTION 417.937
     417.937 Loan and loan guarantee provisions.
42:3.0.1.1.4.19.5.8SECTION 417.940
     417.940 Civil action to enforce compliance with assurances.
42:3.0.1.1.5PART 418
PART 418 - HOSPICE CARE
42:3.0.1.1.5.1SUBPART A
Subpart A - General Provision and Definitions
42:3.0.1.1.5.1.7.1SECTION 418.1
     418.1 Statutory basis.
42:3.0.1.1.5.1.7.2SECTION 418.2
     418.2 Scope of part.
42:3.0.1.1.5.1.7.3SECTION 418.3
     418.3 Definitions.
42:3.0.1.1.5.2SUBPART B
Subpart B - Eligibility, Election and Duration of Benefits
42:3.0.1.1.5.2.7.1SECTION 418.20
     418.20 Eligibility requirements.
42:3.0.1.1.5.2.7.2SECTION 418.21
     418.21 Duration of hospice care coverage - Election periods.
42:3.0.1.1.5.2.7.3SECTION 418.22
     418.22 Certification of terminal illness.
42:3.0.1.1.5.2.7.4SECTION 418.24
     418.24 Election of hospice care.
42:3.0.1.1.5.2.7.5SECTION 418.25
     418.25 Admission to hospice care.
42:3.0.1.1.5.2.7.6SECTION 418.26
     418.26 Discharge from hospice care.
42:3.0.1.1.5.2.7.7SECTION 418.28
     418.28 Revoking the election of hospice care.
42:3.0.1.1.5.2.7.8SECTION 418.30
     418.30 Change of the designated hospice.
42:3.0.1.1.5.3SUBPART C
Subpart C - Conditions of Participation: Patient Care
42:3.0.1.1.5.3.7SUBJGRP 7
  Core Services
42:3.0.1.1.5.3.7.1SECTION 418.52
     418.52 Condition of participation: Patient's rights.
42:3.0.1.1.5.3.7.2SECTION 418.54
     418.54 Condition of participation: Initial and comprehensive assessment of the patient.
42:3.0.1.1.5.3.7.3SECTION 418.56
     418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services.
42:3.0.1.1.5.3.7.4SECTION 418.58
     418.58 Condition of participation: Quality assessment and performance improvement.
42:3.0.1.1.5.3.7.5SECTION 418.60
     418.60 Condition of participation: Infection control.
42:3.0.1.1.5.3.7.6SECTION 418.62
     418.62 Condition of participation: Licensed professional services.
42:3.0.1.1.5.3.7.7SECTION 418.64
     418.64 Condition of participation: Core services.
42:3.0.1.1.5.3.7.8SECTION 418.66
     418.66 Condition of participation: Nursing services - Waiver of requirement that substantially all nursing services be routinely provided directly by a hospice.
42:3.0.1.1.5.3.8SUBJGRP 8
  Non-Core Services
42:3.0.1.1.5.3.8.9SECTION 418.70
     418.70 Condition of participation: Furnishing of non-core services.
42:3.0.1.1.5.3.8.10SECTION 418.72
     418.72 Condition of participation: Physical therapy, occupational therapy, and speech-language pathology.
42:3.0.1.1.5.3.8.11SECTION 418.74
     418.74 Waiver of requirement - Physical therapy, occupational therapy, speech-language pathology, and dietary counseling.
42:3.0.1.1.5.3.8.12SECTION 418.76
     418.76 Condition of participation: Hospice aide and homemaker services.
42:3.0.1.1.5.3.8.13SECTION 418.78
     418.78 Conditions of participation - Volunteers.
42:3.0.1.1.5.4SUBPART D
Subpart D - Conditions of participation: Organizational Environment
42:3.0.1.1.5.4.9.1SECTION 418.100
     418.100 Condition of Participation: Organization and administration of services.
42:3.0.1.1.5.4.9.2SECTION 418.102
     418.102 Condition of participation: Medical director.
42:3.0.1.1.5.4.9.3SECTION 418.104
     418.104 Condition of participation: Clinical records.
42:3.0.1.1.5.4.9.4SECTION 418.106
     418.106 Condition of participation: Drugs and biologicals, medical supplies, and durable medical equipment.
42:3.0.1.1.5.4.9.5SECTION 418.108
     418.108 Condition of participation: Short-term inpatient care.
42:3.0.1.1.5.4.9.6SECTION 418.110
     418.110 Condition of participation: Hospices that provide inpatient care directly.
42:3.0.1.1.5.4.9.7SECTION 418.112
     418.112 Condition of participation: Hospices that provide hospice care to residents of a SNF/NF or ICF/IID.
42:3.0.1.1.5.4.9.8SECTION 418.113
     418.113 Condition of participation: Emergency preparedness.
42:3.0.1.1.5.4.9.9SECTION 418.114
     418.114 Condition of participation: Personnel qualifications.
42:3.0.1.1.5.4.9.10SECTION 418.116
     418.116 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.
42:3.0.1.1.5.5SUBPART E
Subpart E [Reserved]
42:3.0.1.1.5.6SUBPART F
Subpart F - Covered Services
42:3.0.1.1.5.6.9.1SECTION 418.200
     418.200 Requirements for coverage.
42:3.0.1.1.5.6.9.2SECTION 418.202
     418.202 Covered services.
42:3.0.1.1.5.6.9.3SECTION 418.204
     418.204 Special coverage requirements.
42:3.0.1.1.5.6.9.4SECTION 418.205
     418.205 Special requirements for hospice pre-election evaluation and counseling services.
42:3.0.1.1.5.7SUBPART G
Subpart G - Payment for Hospice Care
42:3.0.1.1.5.7.9.1SECTION 418.301
     418.301 Basic rules.
42:3.0.1.1.5.7.9.2SECTION 418.302
     418.302 Payment procedures for hospice care.
42:3.0.1.1.5.7.9.3SECTION 418.304
     418.304 Payment for physician, and nurse practitioner, and physician assistant services.
42:3.0.1.1.5.7.9.4SECTION 418.306
     418.306 Annual update of the payment rates and adjustment for area wage differences.
42:3.0.1.1.5.7.9.5SECTION 418.307
     418.307 Periodic interim payments.
42:3.0.1.1.5.7.9.6SECTION 418.308
     418.308 Limitation on the amount of hospice payments.
42:3.0.1.1.5.7.9.7SECTION 418.309
     418.309 Hospice aggregate cap.
42:3.0.1.1.5.7.9.8SECTION 418.310
     418.310 Reporting and recordkeeping requirements.
42:3.0.1.1.5.7.9.9SECTION 418.311
     418.311 Administrative appeals.
42:3.0.1.1.5.7.9.10SECTION 418.312
     418.312 Data submission requirements under the hospice quality reporting program.
42:3.0.1.1.5.8SUBPART H
Subpart H - Coinsurance
42:3.0.1.1.5.8.9.1SECTION 418.400
     418.400 Individual liability for coinsurance for hospice care.
42:3.0.1.1.5.8.9.2SECTION 418.402
     418.402 Individual liability for services that are not considered hospice care.
42:3.0.1.1.5.8.9.3SECTION 418.405
     418.405 Effect of coinsurance liability on Medicare payment.
42:3.0.1.1.6PART 419
PART 419 - PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT DEPARTMENT SERVICES
42:3.0.1.1.6.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.6.1.9.1SECTION 419.1
     419.1 Basis and scope.
42:3.0.1.1.6.1.9.2SECTION 419.2
     419.2 Basis of payment.
42:3.0.1.1.6.2SUBPART B
Subpart B - Categories of Hospitals and Services Subject to and Excluded From the Hospital Outpatient Prospective Payment System
42:3.0.1.1.6.2.9.1SECTION 419.20
     419.20 Hospitals subject to the hospital outpatient prospective payment system.
42:3.0.1.1.6.2.9.2SECTION 419.21
     419.21 Hospital services subject to the outpatient prospective payment system.
42:3.0.1.1.6.2.9.3SECTION 419.22
     419.22 Hospital services excluded from payment under the hospital outpatient prospective payment system.
42:3.0.1.1.6.3SUBPART C
Subpart C - Basic Methodology for Determining Prospective Payment Rates for Hospital Outpatient Services
42:3.0.1.1.6.3.9.1SECTION 419.30
     419.30 Base expenditure target for calendar year 1999.
42:3.0.1.1.6.3.9.2SECTION 419.31
     419.31 Ambulatory payment classification (APC) system and payment weights.
42:3.0.1.1.6.3.9.3SECTION 419.32
     419.32 Calculation of prospective payment rates for hospital outpatient services.
42:3.0.1.1.6.4SUBPART D
Subpart D - Payments to Hospitals
42:3.0.1.1.6.4.9.1SECTION 419.40
     419.40 Payment concepts.
42:3.0.1.1.6.4.9.2SECTION 419.41
     419.41 Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.
42:3.0.1.1.6.4.9.3SECTION 419.42
     419.42 Hospital election to reduce coinsurance.
42:3.0.1.1.6.4.9.4SECTION 419.43
     419.43 Adjustments to national program payment and beneficiary copayment amounts.
42:3.0.1.1.6.4.9.5SECTION 419.44
     419.44 Payment reductions for procedures.
42:3.0.1.1.6.4.9.6SECTION 419.45
     419.45 Payment and copayment reduction for devices replaced without cost or when full or partial credit is received.
42:3.0.1.1.6.4.9.7SECTION 419.46
     419.46 Participation, data submission, and validation requirements under the Hospital Outpatient Quality Reporting (OQR) Program.
42:3.0.1.1.6.4.9.8SECTION 419.48
     419.48 Definition of excepted items and services.
42:3.0.1.1.6.5SUBPART E
Subpart E - Updates
42:3.0.1.1.6.5.9.1SECTION 419.50
     419.50 Annual review.
42:3.0.1.1.6.6SUBPART F
Subpart F - Limitations on Review
42:3.0.1.1.6.6.9.1SECTION 419.60
     419.60 Limitations on administrative and judicial review.
42:3.0.1.1.6.7SUBPART G
Subpart G - Transitional Pass-through Payments
42:3.0.1.1.6.7.9.1SECTION 419.62
     419.62 Transitional pass-through payments: General rules.
42:3.0.1.1.6.7.9.2SECTION 419.64
     419.64 Transitional pass-through payments: Drugs and biologicals.
42:3.0.1.1.6.7.9.3SECTION 419.66
     419.66 Transitional pass-through payments: Medical devices.
42:3.0.1.1.6.8SUBPART H
Subpart H - Transitional Corridors
42:3.0.1.1.6.8.9.1SECTION 419.70
     419.70 Transitional adjustments to limit decline in payments.
42:3.0.1.1.6.8.9.2SECTION 419.71
     419.71 Payment reduction for certain X-ray imaging services.
42:3.0.1.1.6.9SUBPART I
Subpart I - Prior Authorization for Outpatient Department Services
42:3.0.1.1.6.9.9.1SECTION 419.80
     419.80 Basis and scope of this subpart.
42:3.0.1.1.6.9.9.2SECTION 419.81
     419.81 Definitions.
42:3.0.1.1.6.9.9.3SECTION 419.82
     419.82 Prior authorization for certain covered hospital outpatient department services.
42:3.0.1.1.6.9.9.4SECTION 419.83
     419.83 List of hospital outpatient department services requiring prior authorization.
42:3.0.1.1.6.9.9.5SECTION 419.84-419.89
     419.84-419.89 [Reserved]
42:3.0.1.1.7PART 420
PART 420 - PROGRAM INTEGRITY: MEDICARE
42:3.0.1.1.7.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.7.1.9.1SECTION 420.1
     420.1 Scope and purpose.
42:3.0.1.1.7.1.9.2SECTION 420.3
     420.3 Other related regulations.
42:3.0.1.1.7.2SUBPART B
Subpart B [Reserved]
42:3.0.1.1.7.3SUBPART C
Subpart C - Disclosure of Ownership and Control Information
42:3.0.1.1.7.3.9.1SECTION 420.200
     420.200 Purpose.
42:3.0.1.1.7.3.9.2SECTION 420.201
     420.201 Definitions.
42:3.0.1.1.7.3.9.3SECTION 420.202
     420.202 Determination of ownership or control percentages.
42:3.0.1.1.7.3.9.4SECTION 420.203
     420.203 Disclosure of hiring of intermediary's former employees.
42:3.0.1.1.7.3.9.5SECTION 420.204
     420.204 Principals convicted of a program-related crime.
42:3.0.1.1.7.3.9.6SECTION 420.205
     420.205 Disclosure by providers and part B suppliers of business transaction information.
42:3.0.1.1.7.3.9.7SECTION 420.206
     420.206 Disclosure of persons having ownership, financial, or control interest.
42:3.0.1.1.7.4SUBPART D
Subpart D - Access to Books, Documents, and Records of Subcontractors
42:3.0.1.1.7.4.9.1SECTION 420.300
     420.300 Basis, purpose, and scope.
42:3.0.1.1.7.4.9.2SECTION 420.301
     420.301 Definitions.
42:3.0.1.1.7.4.9.3SECTION 420.302
     420.302 Requirement for access clause in contracts.
42:3.0.1.1.7.4.9.4SECTION 420.303
     420.303 HHS criteria for requesting books, documents, and records.
42:3.0.1.1.7.4.9.5SECTION 420.304
     420.304 Procedures for obtaining access to books, documents, and records.
42:3.0.1.1.7.5SUBPART 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
42:3.0.1.1.7.5.9.1SECTION 420.400
     420.400 Basis and scope.
42:3.0.1.1.7.5.9.2SECTION 420.405
     420.405 Rewards for information relating to Medicare fraud and abuse.
42:3.0.1.1.7.5.9.3SECTION 420.410
     420.410 Establishment of a program to collect suggestions for improving Medicare program efficiency and to reward suggesters for monetary savings.
42:3.0.1.1.8PART 421
PART 421 - MEDICARE CONTRACTING
42:3.0.1.1.8.1SUBPART A
Subpart A - Scope, Definitions, and General Provisions
42:3.0.1.1.8.1.9.1SECTION 421.1
     421.1 Basis, applicability, and scope.
42:3.0.1.1.8.1.9.2SECTION 421.3
     421.3 Definitions.
42:3.0.1.1.8.1.9.3SECTION 421.5
     421.5 General provisions.
42:3.0.1.1.8.2SUBPART B
Subpart B - Intermediaries
42:3.0.1.1.8.2.9.1SECTION 421.100
     421.100 Intermediary functions.
42:3.0.1.1.8.2.9.2SECTION 421.103
     421.103 Payment to providers.
42:3.0.1.1.8.2.9.3SECTION 421.104
     421.104 Assignment of providers of services to intermediaries during transition to Medicare Administrative Contractors (MACs).
42:3.0.1.1.8.2.9.4SECTION 421.110
     421.110 Requirements for approval of an agreement.
42:3.0.1.1.8.2.9.5SECTION 421.112
     421.112 Considerations relating to the effective and efficient administration of the program.
42:3.0.1.1.8.2.9.6SECTION 421.114
     421.114 Assignment and reassignment of providers by CMS.
42:3.0.1.1.8.2.9.7SECTION 421.120
     421.120 Performance criteria.
42:3.0.1.1.8.2.9.8SECTION 421.122
     421.122 Performance standards.
42:3.0.1.1.8.2.9.9SECTION 421.124
     421.124 Intermediary's failure to perform efficiently and effectively.
42:3.0.1.1.8.2.9.10SECTION 421.126
     421.126 Termination of agreements.
42:3.0.1.1.8.2.9.11SECTION 421.128
     421.128 Intermediary's opportunity for hearing and right to judicial review.
42:3.0.1.1.8.3SUBPART C
Subpart C - Carriers
42:3.0.1.1.8.3.9.1SECTION 421.200
     421.200 Carrier functions.
42:3.0.1.1.8.3.9.2SECTION 421.201
     421.201 Performance criteria and standards.
42:3.0.1.1.8.3.9.3SECTION 421.202
     421.202 Requirements and conditions.
42:3.0.1.1.8.3.9.4SECTION 421.203
     421.203 Carrier's failure to perform efficiently and effectively.
42:3.0.1.1.8.3.9.5SECTION 421.205
     421.205 Termination by the Secretary.
42:3.0.1.1.8.3.9.6SECTION 421.210
     421.210 Designations of regional carriers to process claims for durable medical equipment, prosthetics, orthotics and supplies.
42:3.0.1.1.8.3.9.7SECTION 421.212
     421.212 Railroad Retirement Board contracts.
42:3.0.1.1.8.3.9.8SECTION 421.214
     421.214 Advance payments to suppliers furnishing items or services under Part B.
42:3.0.1.1.8.4SUBPART D
Subpart D - Medicare Integrity Program Contractors
42:3.0.1.1.8.4.9.1SECTION 421.300
     421.300 Basis, applicability, and scope.
42:3.0.1.1.8.4.9.2SECTION 421.302
     421.302 Eligibility requirements for Medicare integrity program contractors.
42:3.0.1.1.8.4.9.3SECTION 421.304
     421.304 Medicare integrity program contractor functions.
42:3.0.1.1.8.4.9.4SECTION 421.306
     421.306 Awarding of a contract.
42:3.0.1.1.8.4.9.5SECTION 421.308
     421.308 Renewal of a contract.
42:3.0.1.1.8.4.9.6SECTION 421.310
     421.310 Conflict of interest requirements.
42:3.0.1.1.8.4.9.7SECTION 421.312
     421.312 Conflict of interest resolution.
42:3.0.1.1.8.4.9.8SECTION 421.316
     421.316 Limitation on Medicare integrity program contractor liability.
42:3.0.1.1.8.5SUBPART E
Subpart E - Medicare Administrative Contractors (MACs)
42:3.0.1.1.8.5.9.1SECTION 421.400
     421.400 Statutory basis and scope.
42:3.0.1.1.8.5.9.2SECTION 421.401
     421.401 Definitions.
42:3.0.1.1.8.5.9.3SECTION 421.404
     421.404 Assignment of providers and suppliers to MACs.
42:3.0.1.1.8.6SUBPART F
Subpart F [Reserved]
42:3.0.1.1.9PART 422
PART 422 - MEDICARE ADVANTAGE PROGRAM
42:3.0.1.1.9.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.9.1.9.1SECTION 422.1
     422.1 Basis and scope.
42:3.0.1.1.9.1.9.2SECTION 422.2
     422.2 Definitions.
42:3.0.1.1.9.1.9.3SECTION 422.3
     422.3 xxx
42:3.0.1.1.9.1.9.4SECTION 422.4
     422.4 Types of MA plans.
42:3.0.1.1.9.1.9.5SECTION 422.6
     422.6 Cost-sharing in enrollment-related costs.
42:3.0.1.1.9.2SUBPART B
Subpart B - Eligibility, Election, and Enrollment
42:3.0.1.1.9.2.9.1SECTION 422.50
     422.50 Eligibility to elect an MA plan.
42:3.0.1.1.9.2.9.2SECTION 422.52
     422.52 Eligibility to elect an MA plan for special needs individuals.
42:3.0.1.1.9.2.9.3SECTION 422.53
     422.53 Eligibility to elect an MA plan for senior housing facility residents.
42:3.0.1.1.9.2.9.4SECTION 422.54
     422.54 Continuation of enrollment for MA local plans.
42:3.0.1.1.9.2.9.5SECTION 422.56
     422.56 Enrollment in an MA MSA plan.
42:3.0.1.1.9.2.9.6SECTION 422.57
     422.57 Limited enrollment under MA RFB plans.
42:3.0.1.1.9.2.9.7SECTION 422.60
     422.60 Election process.
42:3.0.1.1.9.2.9.8SECTION 422.62
     422.62 Election of coverage under an MA plan.
42:3.0.1.1.9.2.9.9SECTION 422.64
     422.64 Information about the MA program.
42:3.0.1.1.9.2.9.10SECTION 422.66
     422.66 Coordination of enrollment and disenrollment through MA organizations.
42:3.0.1.1.9.2.9.11SECTION 422.68
     422.68 Effective dates of coverage and change of coverage.
42:3.0.1.1.9.2.9.12SECTION 422.74
     422.74 Disenrollment by the MA organization.
42:3.0.1.1.9.3SUBPART C
Subpart C - Benefits and Beneficiary Protections
42:3.0.1.1.9.3.9.1SECTION 422.100
     422.100 General requirements.
42:3.0.1.1.9.3.9.2SECTION 422.101
     422.101 Requirements relating to basic benefits.
42:3.0.1.1.9.3.9.3SECTION 422.102
     422.102 Supplemental benefits.
42:3.0.1.1.9.3.9.4SECTION 422.103
     422.103 Benefits under an MA MSA plan.
42:3.0.1.1.9.3.9.5SECTION 422.104
     422.104 Special rules on supplemental benefits for MA MSA plans.
42:3.0.1.1.9.3.9.6SECTION 422.105
     422.105 Special rules for self-referral and point of service option.
42:3.0.1.1.9.3.9.7SECTION 422.106
     422.106 Coordination of benefits with employer or union group health plans and Medicaid.
42:3.0.1.1.9.3.9.8SECTION 422.107
     422.107 Special needs plans and dual eligibles: Contract with State Medicaid Agency.
42:3.0.1.1.9.3.9.9SECTION 422.108
     422.108 Medicare secondary payer (MSP) procedures.
42:3.0.1.1.9.3.9.10SECTION 422.109
     422.109 Effect of national coverage determinations (NCDs) and legislative changes in benefits.
42:3.0.1.1.9.3.9.11SECTION 422.110
     422.110 Discrimination against beneficiaries prohibited.
42:3.0.1.1.9.3.9.12SECTION 422.111
     422.111 Disclosure requirements.
42:3.0.1.1.9.3.9.13SECTION 422.112
     422.112 Access to services.
42:3.0.1.1.9.3.9.14SECTION 422.113
     422.113 Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services.
42:3.0.1.1.9.3.9.15SECTION 422.114
     422.114 Access to services under an MA private fee-for-service plan.
42:3.0.1.1.9.3.9.16SECTION 422.116
     422.116 xxx
42:3.0.1.1.9.3.9.17SECTION 422.118
     422.118 Confidentiality and accuracy of enrollee records.
42:3.0.1.1.9.3.9.18SECTION 422.119
     422.119 xxx
42:3.0.1.1.9.3.9.19SECTION 422.120
     422.120 xxx
42:3.0.1.1.9.3.9.20SECTION 422.128
     422.128 Information on advance directives.
42:3.0.1.1.9.3.9.21SECTION 422.132
     422.132 Protection against liability and loss of benefits.
42:3.0.1.1.9.3.9.22SECTION 422.133
     422.133 Return to home skilled nursing facility.
42:3.0.1.1.9.3.9.23SECTION 422.134
     422.134 Reward and incentive programs.
42:3.0.1.1.9.3.9.24SECTION 422.135
     422.135 Additional telehealth benefits.
42:3.0.1.1.9.3.9.25SECTION 422.136
     422.136 Medicare Advantage (MA) and step therapy for Part B drugs.
42:3.0.1.1.9.4SUBPART D
Subpart D - Quality Improvement
42:3.0.1.1.9.4.9.1SECTION 422.152
     422.152 Quality improvement program.
42:3.0.1.1.9.4.9.2SECTION 422.153
     422.153 Use of quality improvement organization review information.
42:3.0.1.1.9.4.9.3SECTION 422.156
     422.156 Compliance deemed on the basis of accreditation.
42:3.0.1.1.9.4.9.4SECTION 422.157
     422.157 Accreditation organizations.
42:3.0.1.1.9.4.9.5SECTION 422.158
     422.158 Procedures for approval of accreditation as a basis for deeming compliance.
42:3.0.1.1.9.4.9.6SECTION 422.160
     422.160 Basis and scope of the Medicare Advantage Quality Rating System.
42:3.0.1.1.9.4.9.7SECTION 422.162
     422.162 Medicare Advantage Quality Rating System.
42:3.0.1.1.9.4.9.8SECTION 422.164
     422.164 Adding, updating, and removing measures.
42:3.0.1.1.9.4.9.9SECTION 422.166
     422.166 Calculation of Star Ratings.
42:3.0.1.1.9.5SUBPART E
Subpart E - Relationships With Providers
42:3.0.1.1.9.5.9.1SECTION 422.200
     422.200 Basis and scope.
42:3.0.1.1.9.5.9.2SECTION 422.202
     422.202 Participation procedures.
42:3.0.1.1.9.5.9.3SECTION 422.204
     422.204 Provider selection and credentialing.
42:3.0.1.1.9.5.9.4SECTION 422.205
     422.205 Provider antidiscrimination rules.
42:3.0.1.1.9.5.9.5SECTION 422.206
     422.206 Interference with health care professionals' advice to enrollees prohibited.
42:3.0.1.1.9.5.9.6SECTION 422.208
     422.208 Physician incentive plans: requirements and limitations.
42:3.0.1.1.9.5.9.7SECTION 422.210
     422.210 Assurances to CMS.
42:3.0.1.1.9.5.9.8SECTION 422.212
     422.212 Limitations on provider indemnification.
42:3.0.1.1.9.5.9.9SECTION 422.214
     422.214 Special rules for services furnished by noncontract providers.
42:3.0.1.1.9.5.9.10SECTION 422.216
     422.216 Special rules for MA private fee-for-service plans.
42:3.0.1.1.9.5.9.11SECTION 422.220
     422.220 Exclusion of services furnished under a private contract.
42:3.0.1.1.9.5.9.12SECTION 422.222
     422.222 Preclusion list for contracted and non-contracted individuals and entities.
42:3.0.1.1.9.5.9.13SECTION 422.224
     422.224 Payment to individuals and entities excluded by the OIG or included on the preclusion list.
42:3.0.1.1.9.6SUBPART F
Subpart F - Submission of Bids, Premiums, and Related Information and Plan Approval
42:3.0.1.1.9.6.9.1SECTION 422.250
     422.250 Basis and scope.
42:3.0.1.1.9.6.9.2SECTION 422.252
     422.252 Terminology.
42:3.0.1.1.9.6.9.3SECTION 422.254
     422.254 Submission of bids.
42:3.0.1.1.9.6.9.4SECTION 422.256
     422.256 Review, negotiation, and approval of bids.
42:3.0.1.1.9.6.9.5SECTION 422.258
     422.258 Calculation of benchmarks.
42:3.0.1.1.9.6.9.6SECTION 422.260
     422.260 Appeals of quality bonus payment determinations.
42:3.0.1.1.9.6.9.7SECTION 422.262
     422.262 Beneficiary premiums.
42:3.0.1.1.9.6.9.8SECTION 422.264
     422.264 Calculation of savings.
42:3.0.1.1.9.6.9.9SECTION 422.266
     422.266 Beneficiary rebates.
42:3.0.1.1.9.6.9.10SECTION 422.270
     422.270 Incorrect collections of premiums and cost-sharing.
42:3.0.1.1.9.6.9.11SECTION 422.272
     422.272 Release of MA bid pricing data.
42:3.0.1.1.9.7SUBPART G
Subpart G - Payments to Medicare Advantage Organizations
42:3.0.1.1.9.7.9.1SECTION 422.300
     422.300 Basis and scope.
42:3.0.1.1.9.7.9.2SECTION 422.304
     422.304 Monthly payments.
42:3.0.1.1.9.7.9.3SECTION 422.306
     422.306 Annual MA capitation rates.
42:3.0.1.1.9.7.9.4SECTION 422.308
     422.308 Adjustments to capitation rates, benchmarks, bids, and payments.
42:3.0.1.1.9.7.9.5SECTION 422.310
     422.310 Risk adjustment data.
42:3.0.1.1.9.7.9.6SECTION 422.311
     422.311 RADV audit dispute and appeal processes.
42:3.0.1.1.9.7.9.7SECTION 422.312
     422.312 Announcement of annual capitation rate, benchmarks, and methodology changes.
42:3.0.1.1.9.7.9.8SECTION 422.314
     422.314 Special rules for beneficiaries enrolled in MA MSA plans.
42:3.0.1.1.9.7.9.9SECTION 422.316
     422.316 Special rules for payments to Federally qualified health centers.
42:3.0.1.1.9.7.9.10SECTION 422.318
     422.318 Special rules for coverage that begins or ends during an inpatient hospital stay.
42:3.0.1.1.9.7.9.11SECTION 422.320
     422.320 Special rules for hospice care.
42:3.0.1.1.9.7.9.12SECTION 422.322
     422.322 Source of payment and effect of MA plan election on payment.
42:3.0.1.1.9.7.9.13SECTION 422.324
     422.324 Payments to MA organizations for graduate medical education costs.
42:3.0.1.1.9.7.9.14SECTION 422.326
     422.326 Reporting and returning of overpayments.
42:3.0.1.1.9.7.9.15SECTION 422.330
     422.330 CMS-identified overpayments associated with payment data submitted by MA organizations.
42:3.0.1.1.9.8SUBPART H
Subpart H - Provider-Sponsored Organizations
42:3.0.1.1.9.8.9.1SECTION 422.350
     422.350 Basis, scope, and definitions.
42:3.0.1.1.9.8.9.2SECTION 422.352
     422.352 Basic requirements.
42:3.0.1.1.9.8.9.3SECTION 422.354
     422.354 Requirements for affiliated providers.
42:3.0.1.1.9.8.9.4SECTION 422.356
     422.356 Determining substantial financial risk and majority financial interest.
42:3.0.1.1.9.8.9.5SECTION 422.370
     422.370 Waiver of State licensure.
42:3.0.1.1.9.8.9.6SECTION 422.372
     422.372 Basis for waiver of State licensure.
42:3.0.1.1.9.8.9.7SECTION 422.374
     422.374 Waiver request and approval process.
42:3.0.1.1.9.8.9.8SECTION 422.376
     422.376 Conditions of the waiver.
42:3.0.1.1.9.8.9.9SECTION 422.378
     422.378 Relationship to State law.
42:3.0.1.1.9.8.9.10SECTION 422.380
     422.380 Solvency standards.
42:3.0.1.1.9.8.9.11SECTION 422.382
     422.382 Minimum net worth amount.
42:3.0.1.1.9.8.9.12SECTION 422.384
     422.384 Financial plan requirement.
42:3.0.1.1.9.8.9.13SECTION 422.386
     422.386 Liquidity.
42:3.0.1.1.9.8.9.14SECTION 422.388
     422.388 Deposits.
42:3.0.1.1.9.8.9.15SECTION 422.390
     422.390 Guarantees.
42:3.0.1.1.9.9SUBPART I
Subpart I - Organization Compliance With State Law and Preemption by Federal Law
42:3.0.1.1.9.9.9.1SECTION 422.400
     422.400 State licensure requirement.
42:3.0.1.1.9.9.9.2SECTION 422.402
     422.402 Federal preemption of State law.
42:3.0.1.1.9.9.9.3SECTION 422.404
     422.404 State premium taxes prohibited.
42:3.0.1.1.9.10SUBPART J
Subpart J - Special Rules for MA Regional Plans
42:3.0.1.1.9.10.9.1SECTION 422.451
     422.451 Moratorium on new local preferred provider organization plans.
42:3.0.1.1.9.10.9.2SECTION 422.455
     422.455 Special rules for MA Regional Plans.
42:3.0.1.1.9.10.9.3SECTION 422.458
     422.458 Risk sharing with regional MA organizations for 2006 and 2007.
42:3.0.1.1.9.11SUBPART K
Subpart K - Application Procedures and Contracts for Medicare Advantage Organizations
42:3.0.1.1.9.11.9.1SECTION 422.500
     422.500 Scope and definitions.
42:3.0.1.1.9.11.9.2SECTION 422.501
     422.501 Application requirements.
42:3.0.1.1.9.11.9.3SECTION 422.502
     422.502 Evaluation and determination procedures.
42:3.0.1.1.9.11.9.4SECTION 422.503
     422.503 General provisions.
42:3.0.1.1.9.11.9.5SECTION 422.504
     422.504 Contract provisions.
42:3.0.1.1.9.11.9.6SECTION 422.505
     422.505 Effective date and term of contract.
42:3.0.1.1.9.11.9.7SECTION 422.506
     422.506 Nonrenewal of contract.
42:3.0.1.1.9.11.9.8SECTION 422.508
     422.508 Modification or termination of contract by mutual consent.
42:3.0.1.1.9.11.9.9SECTION 422.510
     422.510 Termination of contract by CMS.
42:3.0.1.1.9.11.9.10SECTION 422.512
     422.512 Termination of contract by the MA organization.
42:3.0.1.1.9.11.9.11SECTION 422.514
     422.514 Minimum enrollment requirements.
42:3.0.1.1.9.11.9.12SECTION 422.516
     422.516 Validation of Part C reporting requirements.
42:3.0.1.1.9.11.9.13SECTION 422.520
     422.520 Prompt payment by MA organization.
42:3.0.1.1.9.11.9.14SECTION 422.521
     422.521 Effective date of new significant regulatory requirements.
42:3.0.1.1.9.11.9.15SECTION 422.524
     422.524 Special rules for RFB societies.
42:3.0.1.1.9.11.9.16SECTION 422.527
     422.527 Agreements with Federally qualified health centers.
42:3.0.1.1.9.12SUBPART L
Subpart L - Effect of Change of Ownership or Leasing of Facilities During Term of Contract
42:3.0.1.1.9.12.9.1SECTION 422.550
     422.550 General provisions.
42:3.0.1.1.9.12.9.2SECTION 422.552
     422.552 Novation agreement requirements.
42:3.0.1.1.9.12.9.3SECTION 422.553
     422.553 Effect of leasing of an MA organization's facilities.
42:3.0.1.1.9.13SUBPART M
Subpart M - Grievances, Organization Determinations and Appeals
42:3.0.1.1.9.13.9.1SECTION 422.560
     422.560 Basis and scope.
42:3.0.1.1.9.13.9.2SECTION 422.561
     422.561 Definitions.
42:3.0.1.1.9.13.9.3SECTION 422.562
     422.562 General provisions.
42:3.0.1.1.9.13.9.4SECTION 422.564
     422.564 Grievance procedures.
42:3.0.1.1.9.13.9.5SECTION 422.566
     422.566 Organization determinations.
42:3.0.1.1.9.13.9.6SECTION 422.568
     422.568 Standard timeframes and notice requirements for organization determinations.
42:3.0.1.1.9.13.9.7SECTION 422.570
     422.570 Expediting certain organization determinations.
42:3.0.1.1.9.13.9.8SECTION 422.572
     422.572 Timeframes and notice requirements for expedited organization determinations.
42:3.0.1.1.9.13.9.9SECTION 422.574
     422.574 Parties to the organization determination.
42:3.0.1.1.9.13.9.10SECTION 422.576
     422.576 Effect of an organization determination.
42:3.0.1.1.9.13.9.11SECTION 422.578
     422.578 Right to a reconsideration.
42:3.0.1.1.9.13.9.12SECTION 422.580
     422.580 Reconsideration defined.
42:3.0.1.1.9.13.9.13SECTION 422.582
     422.582 Request for a standard reconsideration.
42:3.0.1.1.9.13.9.14SECTION 422.584
     422.584 Expediting certain reconsiderations.
42:3.0.1.1.9.13.9.15SECTION 422.586
     422.586 Opportunity to submit evidence.
42:3.0.1.1.9.13.9.16SECTION 422.590
     422.590 Timeframes and responsibility for reconsiderations.
42:3.0.1.1.9.13.9.17SECTION 422.592
     422.592 Reconsideration by an independent entity.
42:3.0.1.1.9.13.9.18SECTION 422.594
     422.594 Notice of reconsidered determination by the independent entity.
42:3.0.1.1.9.13.9.19SECTION 422.596
     422.596 Effect of a reconsidered determination.
42:3.0.1.1.9.13.9.20SECTION 422.600
     422.600 Right to a hearing.
42:3.0.1.1.9.13.9.21SECTION 422.602
     422.602 Request for an ALJ hearing.
42:3.0.1.1.9.13.9.22SECTION 422.608
     422.608 Medicare Appeals Council (Council) review.
42:3.0.1.1.9.13.9.23SECTION 422.612
     422.612 Judicial review.
42:3.0.1.1.9.13.9.24SECTION 422.616
     422.616 Reopening and revising determinations and decisions.
42:3.0.1.1.9.13.9.25SECTION 422.618
     422.618 How an MA organization must effectuate standard reconsidered determinations or decisions.
42:3.0.1.1.9.13.9.26SECTION 422.619
     422.619 How an MA organization must effectuate expedited reconsidered determinations.
42:3.0.1.1.9.13.9.27SECTION 422.620
     422.620 Notifying enrollees of hospital discharge appeal rights.
42:3.0.1.1.9.13.9.28SECTION 422.622
     422.622 Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
42:3.0.1.1.9.13.9.29SECTION 422.624
     422.624 Notifying enrollees of termination of provider services.
42:3.0.1.1.9.13.9.30SECTION 422.626
     422.626 Fast-track appeals of service terminations to independent review entities (IREs).
42:3.0.1.1.9.13.9.31SECTION 422.629
     422.629 xxx
42:3.0.1.1.9.13.9.32SECTION 422.630
     422.630 xxx
42:3.0.1.1.9.13.9.33SECTION 422.631
     422.631 xxx
42:3.0.1.1.9.13.9.34SECTION 422.632
     422.632 xxx
42:3.0.1.1.9.13.9.35SECTION 422.633
     422.633 xxx
42:3.0.1.1.9.13.9.36SECTION 422.634
     422.634 xxx
42:3.0.1.1.9.14SUBPART N
Subpart N - Medicare Contract Determinations and Appeals
42:3.0.1.1.9.14.9.1SECTION 422.641
     422.641 Contract determinations.
42:3.0.1.1.9.14.9.2SECTION 422.644
     422.644 Notice of contract determination.
42:3.0.1.1.9.14.9.3SECTION 422.646
     422.646 Effect of contract determination.
42:3.0.1.1.9.14.9.4SECTION 422.660
     422.660 Right to a hearing, burden of proof, standard of proof, and standards of review.
42:3.0.1.1.9.14.9.5SECTION 422.662
     422.662 Request for hearing.
42:3.0.1.1.9.14.9.6SECTION 422.664
     422.664 Postponement of effective date of a contract determination when a request for a hearing is filed timely.
42:3.0.1.1.9.14.9.7SECTION 422.666
     422.666 Designation of hearing officer.
42:3.0.1.1.9.14.9.8SECTION 422.668
     422.668 Disqualification of hearing officer.
42:3.0.1.1.9.14.9.9SECTION 422.670
     422.670 Time and place of hearing.
42:3.0.1.1.9.14.9.10SECTION 422.672
     422.672 Appointment of representatives.
42:3.0.1.1.9.14.9.11SECTION 422.674
     422.674 Authority of representatives.
42:3.0.1.1.9.14.9.12SECTION 422.676
     422.676 Conduct of hearing.
42:3.0.1.1.9.14.9.13SECTION 422.678
     422.678 Evidence.
42:3.0.1.1.9.14.9.14SECTION 422.680
     422.680 Witnesses.
42:3.0.1.1.9.14.9.15SECTION 422.682
     422.682 Witness lists and documents.
42:3.0.1.1.9.14.9.16SECTION 422.684
     422.684 Prehearing and summary judgment.
42:3.0.1.1.9.14.9.17SECTION 422.686
     422.686 Record of hearing.
42:3.0.1.1.9.14.9.18SECTION 422.688
     422.688 Authority of hearing officer.
42:3.0.1.1.9.14.9.19SECTION 422.690
     422.690 Notice and effect of hearing decision.
42:3.0.1.1.9.14.9.20SECTION 422.692
     422.692 Review by the Administrator.
42:3.0.1.1.9.14.9.21SECTION 422.694
     422.694 Effect of Administrator's decision.
42:3.0.1.1.9.14.9.22SECTION 422.696
     422.696 Reopening of a contract determination or decision of a hearing officer or the Administrator.
42:3.0.1.1.9.15SUBPART O
Subpart O - Intermediate Sanctions
42:3.0.1.1.9.15.9.1SECTION 422.750
     422.750 Types of intermediate sanctions and civil money penalties.
42:3.0.1.1.9.15.9.2SECTION 422.752
     422.752 Basis for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.9.15.9.3SECTION 422.756
     422.756 Procedures for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.9.15.9.4SECTION 422.758
     422.758 Collection of civil money penalties imposed by CMS.
42:3.0.1.1.9.15.9.5SECTION 422.760
     422.760 Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
42:3.0.1.1.9.15.9.6SECTION 422.762
     422.762 Settlement of penalties.
42:3.0.1.1.9.15.9.7SECTION 422.764
     422.764 Other applicable provisions.
42:3.0.1.1.9.16SUBPART P
Subparts P-S [Reserved]
42:3.0.1.1.9.17SUBPART T
Subpart T - Appeal procedures for Civil Money Penalties
42:3.0.1.1.9.17.9.1SECTION 422.1000
     422.1000 Basis and scope.
42:3.0.1.1.9.17.9.2SECTION 422.1002
     422.1002 Definitions.
42:3.0.1.1.9.17.9.3SECTION 422.1004
     422.1004 Scope and applicability.
42:3.0.1.1.9.17.9.4SECTION 422.1006
     422.1006 Appeal rights.
42:3.0.1.1.9.17.9.5SECTION 422.1008
     422.1008 Appointment of representatives.
42:3.0.1.1.9.17.9.6SECTION 422.1010
     422.1010 Authority of representatives.
42:3.0.1.1.9.17.9.7SECTION 422.1012
     422.1012 Fees for services of representatives.
42:3.0.1.1.9.17.9.8SECTION 422.1014
     422.1014 Charge for transcripts.
42:3.0.1.1.9.17.9.9SECTION 422.1016
     422.1016 Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
42:3.0.1.1.9.17.9.10SECTION 422.1018
     422.1018 Notice and effect of initial determinations.
42:3.0.1.1.9.17.9.11SECTION 422.1020
     422.1020 Request for hearing.
42:3.0.1.1.9.17.9.12SECTION 422.1022
     422.1022 Parties to the hearing.
42:3.0.1.1.9.17.9.13SECTION 422.1024
     422.1024 Designation of hearing official.
42:3.0.1.1.9.17.9.14SECTION 422.1026
     422.1026 Disqualification of Administrative Law Judge.
42:3.0.1.1.9.17.9.15SECTION 422.1028
     422.1028 Prehearing conference.
42:3.0.1.1.9.17.9.16SECTION 422.1030
     422.1030 Notice of prehearing conference.
42:3.0.1.1.9.17.9.17SECTION 422.1032
     422.1032 Conduct of prehearing conference.
42:3.0.1.1.9.17.9.18SECTION 422.1034
     422.1034 Record, order, and effect of prehearing conference.
42:3.0.1.1.9.17.9.19SECTION 422.1036
     422.1036 Time and place of hearing.
42:3.0.1.1.9.17.9.20SECTION 422.1038
     422.1038 Change in time and place of hearing.
42:3.0.1.1.9.17.9.21SECTION 422.1040
     422.1040 Joint hearings.
42:3.0.1.1.9.17.9.22SECTION 422.1042
     422.1042 Hearing on new issues.
42:3.0.1.1.9.17.9.23SECTION 422.1044
     422.1044 Subpoenas.
42:3.0.1.1.9.17.9.24SECTION 422.1046
     422.1046 Conduct of hearing.
42:3.0.1.1.9.17.9.25SECTION 422.1048
     422.1048 Evidence.
42:3.0.1.1.9.17.9.26SECTION 422.1050
     422.1050 Witnesses.
42:3.0.1.1.9.17.9.27SECTION 422.1052
     422.1052 Oral and written summation.
42:3.0.1.1.9.17.9.28SECTION 422.1054
     422.1054 Record of hearing.
42:3.0.1.1.9.17.9.29SECTION 422.1056
     422.1056 Waiver of right to appear and present evidence.
42:3.0.1.1.9.17.9.30SECTION 422.1058
     422.1058 Dismissal of request for hearing.
42:3.0.1.1.9.17.9.31SECTION 422.1060
     422.1060 Dismissal for abandonment.
42:3.0.1.1.9.17.9.32SECTION 422.1062
     422.1062 Dismissal for cause.
42:3.0.1.1.9.17.9.33SECTION 422.1064
     422.1064 Notice and effect of dismissal and right to request review.
42:3.0.1.1.9.17.9.34SECTION 422.1066
     422.1066 Vacating a dismissal of request for hearing.
42:3.0.1.1.9.17.9.35SECTION 422.1068
     422.1068 Administrative Law Judge's decision.
42:3.0.1.1.9.17.9.36SECTION 422.1070
     422.1070 Removal of hearing to Departmental Appeals Board.
42:3.0.1.1.9.17.9.37SECTION 422.1072
     422.1072 Remand by the Administrative Law Judge.
42:3.0.1.1.9.17.9.38SECTION 422.1074
     422.1074 Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
42:3.0.1.1.9.17.9.39SECTION 422.1076
     422.1076 Request for Departmental Appeals Board review.
42:3.0.1.1.9.17.9.40SECTION 422.1078
     422.1078 Departmental Appeals Board action on request for review.
42:3.0.1.1.9.17.9.41SECTION 422.1080
     422.1080 Procedures before the Departmental Appeals Board on review.
42:3.0.1.1.9.17.9.42SECTION 422.1082
     422.1082 Evidence admissible on review.
42:3.0.1.1.9.17.9.43SECTION 422.1084
     422.1084 Decision or remand by the Departmental Appeals Board.
42:3.0.1.1.9.17.9.44SECTION 422.1086
     422.1086 Effect of Departmental Appeals Board Decision.
42:3.0.1.1.9.17.9.45SECTION 422.1088
     422.1088 Extension of time for seeking judicial review.
42:3.0.1.1.9.17.9.46SECTION 422.1090
     422.1090 Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
42:3.0.1.1.9.17.9.47SECTION 422.1092
     422.1092 Revision of reopened decision.
42:3.0.1.1.9.17.9.48SECTION 422.1094
     422.1094 Notice and effect of revised decision.
42:3.0.1.1.9.18SUBPART U
Subpart U [Reserved]
42:3.0.1.1.9.19SUBPART V
Subpart V - Medicare Advantage Communication Requirements
42:3.0.1.1.9.19.9.1SECTION 422.2260
     422.2260 Definitions.
42:3.0.1.1.9.19.9.2SECTION 422.2262
     422.2262 Review and distribution of marketing materials.
42:3.0.1.1.9.19.9.3SECTION 422.2264
     422.2264 Guidelines for CMS review.
42:3.0.1.1.9.19.9.4SECTION 422.2266
     422.2266 [Reserved]
42:3.0.1.1.9.19.9.5SECTION 422.2268
     422.2268 Standards for MA organization communications and marketing.
42:3.0.1.1.9.19.9.6SECTION 422.2272
     422.2272 Licensing of marketing representatives and confirmation of marketing resources.
42:3.0.1.1.9.19.9.7SECTION 422.2274
     422.2274 Broker and agent requirements.
42:3.0.1.1.9.19.9.8SECTION 422.2276
     422.2276 Employer group retiree marketing.
42:3.0.1.1.9.20SUBPART W
Subpart W [Reserved]
42:3.0.1.1.9.21SUBPART X
Subpart X - Requirements for a Minimum Medical Loss Ratio
42:3.0.1.1.9.21.9.1SECTION 422.2400
     422.2400 Basis and scope.
42:3.0.1.1.9.21.9.2SECTION 422.2401
     422.2401 Definitions.
42:3.0.1.1.9.21.9.3SECTION 422.2410
     422.2410 General requirements.
42:3.0.1.1.9.21.9.4SECTION 422.2420
     422.2420 Calculation of the medical loss ratio.
42:3.0.1.1.9.21.9.5SECTION 422.2430
     422.2430 Activities that improve health care quality.
42:3.0.1.1.9.21.9.6SECTION 422.2440
     422.2440 Credibility adjustment.
42:3.0.1.1.9.21.9.7SECTION 422.2450
     422.2450 [Reserved]
42:3.0.1.1.9.21.9.8SECTION 422.2460
     422.2460 Reporting requirements.
42:3.0.1.1.9.21.9.9SECTION 422.2470
     422.2470 Remittance to CMS if the applicable MLR requirement is not met.
42:3.0.1.1.9.21.9.10SECTION 422.2480
     422.2480 MLR review and non-compliance.
42:3.0.1.1.9.21.9.11SECTION 422.2490
     422.2490 Release of Part C MLR data.
42:3.0.1.1.9.22SUBPART Y
Subpart Y [Reserved]
42:3.0.1.1.9.23SUBPART Z
Subpart Z - Part C Recovery Audit Contractor Appeals Process
42:3.0.1.1.9.23.9.1SECTION 422.2600
     422.2600 Payment appeals.
42:3.0.1.1.9.23.9.2SECTION 422.2605
     422.2605 Request for reconsideration.
42:3.0.1.1.9.23.9.3SECTION 422.2610
     422.2610 Hearing official review.
42:3.0.1.1.9.23.9.4SECTION 422.2615
     422.2615 Review by the Administrator.
42:3.0.1.1.10PART 423
PART 423 - VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT
42:3.0.1.1.10.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.10.1.9.1SECTION 423.1
     423.1 Basis and scope.
42:3.0.1.1.10.1.9.2SECTION 423.4
     423.4 Definitions.
42:3.0.1.1.10.1.9.3SECTION 423.6
     423.6 Cost-sharing in beneficiary education and enrollment-related costs.
42:3.0.1.1.10.2SUBPART B
Subpart B - Eligibility and Enrollment
42:3.0.1.1.10.2.9.1SECTION 423.30
     423.30 Eligibility and enrollment.
42:3.0.1.1.10.2.9.2SECTION 423.32
     423.32 Enrollment process.
42:3.0.1.1.10.2.9.3SECTION 423.34
     423.34 Enrollment of low-income subsidy eligible individuals.
42:3.0.1.1.10.2.9.4SECTION 423.36
     423.36 Disenrollment process.
42:3.0.1.1.10.2.9.5SECTION 423.38
     423.38 Enrollment periods.
42:3.0.1.1.10.2.9.6SECTION 423.40
     423.40 Effective dates.
42:3.0.1.1.10.2.9.7SECTION 423.44
     423.44 Involuntary disenrollment from Part D coverage.
42:3.0.1.1.10.2.9.8SECTION 423.46
     423.46 Late enrollment penalty.
42:3.0.1.1.10.2.9.9SECTION 423.48
     423.48 Information about Part D.
42:3.0.1.1.10.2.9.10SECTION 423.56
     423.56 Procedures to determine and document creditable status of prescription drug coverage.
42:3.0.1.1.10.3SUBPART C
Subpart C - Benefits and Beneficiary Protections
42:3.0.1.1.10.3.9.1SECTION 423.100
     423.100 Definitions.
42:3.0.1.1.10.3.9.2SECTION 423.104
     423.104 Requirements related to qualified prescription drug coverage.
42:3.0.1.1.10.3.9.3SECTION 423.112
     423.112 Establishment of prescription drug plan service areas.
42:3.0.1.1.10.3.9.4SECTION 423.120
     423.120 Access to covered Part D drugs.
42:3.0.1.1.10.3.9.5SECTION 423.124
     423.124 Special rules for out-of-network access to covered Part D drugs at out-of-network pharmacies.
42:3.0.1.1.10.3.9.6SECTION 423.128
     423.128 Dissemination of Part D plan information.
42:3.0.1.1.10.3.9.7SECTION 423.132
     423.132 Public disclosure of pharmaceutical prices for equivalent drugs.
42:3.0.1.1.10.3.9.8SECTION 423.136
     423.136 Privacy, confidentiality, and accuracy of enrollee records.
42:3.0.1.1.10.4SUBPART D
Subpart D - Cost Control and Quality Improvement Requirements
42:3.0.1.1.10.4.9.1SECTION 423.150
     423.150 Scope.
42:3.0.1.1.10.4.9.2SECTION 423.153
     423.153 Prescription drug plan sponsors' access to Medicare Parts A and B claims data extracts.
42:3.0.1.1.10.4.9.3SECTION 423.154
     423.154 Appropriate dispensing of prescription drugs in long-term care facilities under PDPs and MA-PD plans.
42:3.0.1.1.10.4.9.4SECTION 423.156
     423.156 Consumer satisfaction surveys.
42:3.0.1.1.10.4.9.5SECTION 423.159
     423.159 Electronic prescription drug program.
42:3.0.1.1.10.4.9.6SECTION 423.160
     423.160 Standards for electronic prescribing.
42:3.0.1.1.10.4.9.7SECTION 423.162
     423.162 Quality improvement organization activities.
42:3.0.1.1.10.4.9.8SECTION 423.165
     423.165 Compliance deemed on the basis of accreditation.
42:3.0.1.1.10.4.9.9SECTION 423.168
     423.168 Accreditation organizations.
42:3.0.1.1.10.4.9.10SECTION 423.171
     423.171 Procedures for approval of accreditation as a basis for deeming compliance.
42:3.0.1.1.10.4.9.11SECTION 423.180
     423.180 Basis and scope of the Part D Prescription Drug Plan Quality Rating System.
42:3.0.1.1.10.4.9.12SECTION 423.182
     423.182 Part D Prescription Drug Plan Quality Rating System.
42:3.0.1.1.10.4.9.13SECTION 423.184
     423.184 Adding, updating, and removing measures.
42:3.0.1.1.10.4.9.14SECTION 423.186
     423.186 Calculation of Star Ratings.
42:3.0.1.1.10.5SUBPART E
Subpart E [Reserved]
42:3.0.1.1.10.6SUBPART F
Subpart F - Submission of Bids and Monthly Beneficiary Premiums; Plan Approval
42:3.0.1.1.10.6.9.1SECTION 423.251
     423.251 Scope.
42:3.0.1.1.10.6.9.2SECTION 423.258
     423.258 Definitions.
42:3.0.1.1.10.6.9.3SECTION 423.265
     423.265 Submission of bids and related information.
42:3.0.1.1.10.6.9.4SECTION 423.272
     423.272 Review and negotiation of bid and approval of plans submitted by potential Part D sponsors.
42:3.0.1.1.10.6.9.5SECTION 423.279
     423.279 National average monthly bid amount.
42:3.0.1.1.10.6.9.6SECTION 423.286
     423.286 Rules regarding premiums.
42:3.0.1.1.10.6.9.7SECTION 423.293
     423.293 Collection of monthly beneficiary premium.
42:3.0.1.1.10.7SUBPART G
Subpart G - Payments to Part D Plan Sponsors For Qualified Prescription Drug Coverage
42:3.0.1.1.10.7.9.1SECTION 423.301
     423.301 Scope.
42:3.0.1.1.10.7.9.2SECTION 423.308
     423.308 Definitions and terminology.
42:3.0.1.1.10.7.9.3SECTION 423.315
     423.315 General payment provisions.
42:3.0.1.1.10.7.9.4SECTION 423.322
     423.322 Requirement for disclosure of information.
42:3.0.1.1.10.7.9.5SECTION 423.329
     423.329 Determination of payments.
42:3.0.1.1.10.7.9.6SECTION 423.336
     423.336 Risk-sharing arrangements.
42:3.0.1.1.10.7.9.7SECTION 423.343
     423.343 Retroactive adjustments and reconciliations.
42:3.0.1.1.10.7.9.8SECTION 423.346
     423.346 Reopening.
42:3.0.1.1.10.7.9.9SECTION 423.350
     423.350 Payment appeals.
42:3.0.1.1.10.7.9.10SECTION 423.352
     423.352 CMS-identified overpayments associated with payment data submitted by Part D sponsors.
42:3.0.1.1.10.7.9.11SECTION 423.360
     423.360 Reporting and returning of overpayments.
42:3.0.1.1.10.8SUBPART H
Subpart H [Reserved]
42:3.0.1.1.10.9SUBPART I
Subpart I - Organization Compliance with State Law and Preemption by Federal Law
42:3.0.1.1.10.9.9.1SECTION 423.401
     423.401 General requirements for PDP sponsors.
42:3.0.1.1.10.9.9.2SECTION 423.410
     423.410 Waiver of certain requirements to expand choice.
42:3.0.1.1.10.9.9.3SECTION 423.415
     423.415 Temporary waivers for entities seeking to offer a prescription drug plan in more than one State in a region
42:3.0.1.1.10.9.9.4SECTION 423.420
     423.420 Solvency standards for non-licensed entities.
42:3.0.1.1.10.9.9.5SECTION 423.425
     423.425 Licensure does not substitute for or constitute certification.
42:3.0.1.1.10.9.9.6SECTION 423.440
     423.440 Prohibition of State imposition of premium taxes; relation to State laws.
42:3.0.1.1.10.10SUBPART J
Subpart J - Coordination of Part D Plans With Other Prescription Drug Coverage
42:3.0.1.1.10.10.9.1SECTION 423.452
     423.452 Scope.
42:3.0.1.1.10.10.9.2SECTION 423.454
     423.454 Definitions.
42:3.0.1.1.10.10.9.3SECTION 423.458
     423.458 Application of Part D rules to certain Part D plans on and after January 1, 2006.
42:3.0.1.1.10.10.9.4SECTION 423.462
     423.462 Medicare secondary payer procedures.
42:3.0.1.1.10.10.9.5SECTION 423.464
     423.464 Coordination of benefits with other providers of prescription drug coverage.
42:3.0.1.1.10.10.9.6SECTION 423.466
     423.466 Timeframes for coordination of benefits and claims adjustments.
42:3.0.1.1.10.11SUBPART K
Subpart K - Application Procedures and Contracts with Part D plan sponsors
42:3.0.1.1.10.11.9.1SECTION 423.500
     423.500 Scope.
42:3.0.1.1.10.11.9.2SECTION 423.501
     423.501 Definitions
42:3.0.1.1.10.11.9.3SECTION 423.502
     423.502 Application requirements.
42:3.0.1.1.10.11.9.4SECTION 423.503
     423.503 Evaluation and determination procedures for applications to be determined qualified to act as a sponsor.
42:3.0.1.1.10.11.9.5SECTION 423.504
     423.504 General provisions.
42:3.0.1.1.10.11.9.6SECTION 423.505
     423.505 Contract provisions.
42:3.0.1.1.10.11.9.7SECTION 423.506
     423.506 Effective date and term of contract.
42:3.0.1.1.10.11.9.8SECTION 423.507
     423.507 Nonrenewal of contract.
42:3.0.1.1.10.11.9.9SECTION 423.508
     423.508 Modification or termination of contract by mutual consent.
42:3.0.1.1.10.11.9.10SECTION 423.509
     423.509 Termination of contract by CMS.
42:3.0.1.1.10.11.9.11SECTION 423.510
     423.510 Termination of contract by the Part D sponsor.
42:3.0.1.1.10.11.9.12SECTION 423.512
     423.512 Minimum enrollment requirements.
42:3.0.1.1.10.11.9.13SECTION 423.514
     423.514 Validation of Part D reporting requirements.
42:3.0.1.1.10.11.9.14SECTION 423.516
     423.516 Prohibition of midyear implementation of significant new regulatory requirements.
42:3.0.1.1.10.11.9.15SECTION 423.520
     423.520 Prompt payment by Part D sponsors.
42:3.0.1.1.10.12SUBPART L
Subpart L - Effect of Change of Ownership or Leasing of Facilities During Term of Contract
42:3.0.1.1.10.12.9.1SECTION 423.551
     423.551 General provisions.
42:3.0.1.1.10.12.9.2SECTION 423.552
     423.552 Novation agreement requirements.
42:3.0.1.1.10.12.9.3SECTION 423.553
     423.553 Effect of leasing of a PDP sponsor's facilities.
42:3.0.1.1.10.13SUBPART M
Subpart M - Grievances, Coverage Determinations, Redeterminations, and Reconsiderations
42:3.0.1.1.10.13.9.1SECTION 423.558
     423.558 Scope.
42:3.0.1.1.10.13.9.2SECTION 423.560
     423.560 Definitions.
42:3.0.1.1.10.13.9.3SECTION 423.562
     423.562 General provisions.
42:3.0.1.1.10.13.9.4SECTION 423.564
     423.564 Grievance procedures.
42:3.0.1.1.10.13.9.5SECTION 423.566
     423.566 Coverage determinations.
42:3.0.1.1.10.13.9.6SECTION 423.568
     423.568 Standard timeframe and notice requirements for coverage determinations.
42:3.0.1.1.10.13.9.7SECTION 423.570
     423.570 Expediting certain coverage determinations.
42:3.0.1.1.10.13.9.8SECTION 423.572
     423.572 Timeframes and notice requirements for expedited coverage determinations.
42:3.0.1.1.10.13.9.9SECTION 423.576
     423.576 Effect of a coverage determination.
42:3.0.1.1.10.13.9.10SECTION 423.578
     423.578 Exceptions process.
42:3.0.1.1.10.13.9.11SECTION 423.580
     423.580 Right to a redetermination.
42:3.0.1.1.10.13.9.12SECTION 423.582
     423.582 Request for a standard redetermination.
42:3.0.1.1.10.13.9.13SECTION 423.584
     423.584 Expediting certain redeterminations.
42:3.0.1.1.10.13.9.14SECTION 423.586
     423.586 Opportunity to submit evidence.
42:3.0.1.1.10.13.9.15SECTION 423.590
     423.590 Timeframes and responsibility for making redeterminations.
42:3.0.1.1.10.13.9.16SECTION 423.600
     423.600 Reconsideration by an independent review entity (IRE).
42:3.0.1.1.10.13.9.17SECTION 423.602
     423.602 Notice of reconsideration determination by the independent review entity.
42:3.0.1.1.10.13.9.18SECTION 423.604
     423.604 Effect of a reconsideration determination.
42:3.0.1.1.10.13.9.19SECTION 423.610-423.634
     423.610-423.634 [Reserved]
42:3.0.1.1.10.13.9.20SECTION 423.636
     423.636 How a Part D plan sponsor must effectuate standard redeterminations, reconsiderations, or decisions.
42:3.0.1.1.10.13.9.21SECTION 423.638
     423.638 How a Part D plan sponsor must effectuate expedited redeterminations or reconsiderations.
42:3.0.1.1.10.14SUBPART N
Subpart N - Medicare Contract Determinations and Appeals
42:3.0.1.1.10.14.9.1SECTION 423.641
     423.641 Contract determinations.
42:3.0.1.1.10.14.9.2SECTION 423.642
     423.642 Notice of contract determination.
42:3.0.1.1.10.14.9.3SECTION 423.643
     423.643 Effect of contract determination.
42:3.0.1.1.10.14.9.4SECTION 423.650
     423.650 Right to a hearing, burden of proof, standard of proof, and standards of review.
42:3.0.1.1.10.14.9.5SECTION 423.651
     423.651 Request for hearing.
42:3.0.1.1.10.14.9.6SECTION 423.652
     423.652 Postponement of effective date of a contract determination when a request for a hearing is filed timely.
42:3.0.1.1.10.14.9.7SECTION 423.653
     423.653 Designation of hearing officer.
42:3.0.1.1.10.14.9.8SECTION 423.654
     423.654 Disqualification of hearing officer.
42:3.0.1.1.10.14.9.9SECTION 423.655
     423.655 Time and place of hearing.
42:3.0.1.1.10.14.9.10SECTION 423.656
     423.656 Appointment of representatives.
42:3.0.1.1.10.14.9.11SECTION 423.657
     423.657 Authority of representatives.
42:3.0.1.1.10.14.9.12SECTION 423.658
     423.658 Conduct of hearing.
42:3.0.1.1.10.14.9.13SECTION 423.659
     423.659 Evidence.
42:3.0.1.1.10.14.9.14SECTION 423.660
     423.660 Witnesses.
42:3.0.1.1.10.14.9.15SECTION 423.661
     423.661 Witnesses lists and documents.
42:3.0.1.1.10.14.9.16SECTION 423.662
     423.662 Prehearing and summary judgment.
42:3.0.1.1.10.14.9.17SECTION 423.663
     423.663 Record of hearing.
42:3.0.1.1.10.14.9.18SECTION 423.664
     423.664 Authority of hearing officer.
42:3.0.1.1.10.14.9.19SECTION 423.665
     423.665 Notice and effect of hearing decision.
42:3.0.1.1.10.14.9.20SECTION 423.666
     423.666 Review by the Administrator.
42:3.0.1.1.10.14.9.21SECTION 423.667
     423.667 Effect of Administrator's decision.
42:3.0.1.1.10.14.9.22SECTION 423.668
     423.668 Reopening of a contract determination or decision of a hearing officer or the Administrator.
42:3.0.1.1.10.15SUBPART O
Subpart O - Intermediate Sanctions
42:3.0.1.1.10.15.9.1SECTION 423.750
     423.750 Types of intermediate sanctions and civil money penalties.
42:3.0.1.1.10.15.9.2SECTION 423.752
     423.752 Basis for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.10.15.9.3SECTION 423.756
     423.756 Procedures for imposing intermediate sanctions and civil money penalties.
42:3.0.1.1.10.15.9.4SECTION 423.758
     423.758 Collection of civil money penalties imposed by CMS.
42:3.0.1.1.10.15.9.5SECTION 423.760
     423.760 Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
42:3.0.1.1.10.15.9.6SECTION 423.762
     423.762 Settlement of penalties.
42:3.0.1.1.10.15.9.7SECTION 423.764
     423.764 Other applicable provisions.
42:3.0.1.1.10.16SUBPART P
Subpart P - Premiums and Cost-Sharing Subsidies for Low-Income Individuals
42:3.0.1.1.10.16.9.1SECTION 423.771
     423.771 Basis and scope.
42:3.0.1.1.10.16.9.2SECTION 423.772
     423.772 Definitions.
42:3.0.1.1.10.16.9.3SECTION 423.773
     423.773 Requirements for eligibility.
42:3.0.1.1.10.16.9.4SECTION 423.774
     423.774 Eligibility determinations, redeterminations, and applications.
42:3.0.1.1.10.16.9.5SECTION 423.780
     423.780 Premium subsidy.
42:3.0.1.1.10.16.9.6SECTION 423.782
     423.782 Cost-sharing subsidy.
42:3.0.1.1.10.16.9.7SECTION 423.800
     423.800 Administration of subsidy program.
42:3.0.1.1.10.17SUBPART Q
Subpart Q - Guaranteeing Access to a Choice of Coverage (Fallback Prescription Drug Plans)
42:3.0.1.1.10.17.9.1SECTION 423.851
     423.851 Scope.
42:3.0.1.1.10.17.9.2SECTION 423.855
     423.855 Definitions.
42:3.0.1.1.10.17.9.3SECTION 423.859
     423.859 Assuring access to a choice of coverage.
42:3.0.1.1.10.17.9.4SECTION 423.863
     423.863 Submission and approval of bids.
42:3.0.1.1.10.17.9.5SECTION 423.867
     423.867 Rules regarding premiums.
42:3.0.1.1.10.17.9.6SECTION 423.871
     423.871 Contract terms and conditions.
42:3.0.1.1.10.17.9.7SECTION 423.875
     423.875 Payment to fallback plans.
42:3.0.1.1.10.18SUBPART R
Subpart R - Payments to Sponsors of Retiree Prescription Drug Plans
42:3.0.1.1.10.18.9.1SECTION 423.880
     423.880 Basis and scope.
42:3.0.1.1.10.18.9.2SECTION 423.882
     423.882 Definitions.
42:3.0.1.1.10.18.9.3SECTION 423.884
     423.884 Requirements for qualified retiree prescription drug plans.
42:3.0.1.1.10.18.9.4SECTION 423.886
     423.886 Retiree drug subsidy amounts.
42:3.0.1.1.10.18.9.5SECTION 423.888
     423.888 Payment methods, including provision of necessary information.
42:3.0.1.1.10.18.9.6SECTION 423.890
     423.890 Appeals.
42:3.0.1.1.10.18.9.7SECTION 423.892
     423.892 Change of ownership.
42:3.0.1.1.10.18.9.8SECTION 423.894
     423.894 Construction.
42:3.0.1.1.10.19SUBPART S
Subpart S - Special Rules for States-Eligibility Determinations for Subsidies and General Payment Provisions
42:3.0.1.1.10.19.9.1SECTION 423.900
     423.900 Basis and scope.
42:3.0.1.1.10.19.9.2SECTION 423.902
     423.902 Definitions.
42:3.0.1.1.10.19.9.3SECTION 423.904
     423.904 Eligibility determinations for low-income subsidies.
42:3.0.1.1.10.19.9.4SECTION 423.906
     423.906 General payment provisions.
42:3.0.1.1.10.19.9.5SECTION 423.907
     423.907 Treatment of territories.
42:3.0.1.1.10.19.9.6SECTION 423.908.
     423.908. Phased-down State contribution to drug benefit costs assumed by Medicare.
42:3.0.1.1.10.19.9.7SECTION 423.910
     423.910 Requirements.
42:3.0.1.1.10.20SUBPART T
Subpart T - Appeal Procedures for Civil Money Penalties
42:3.0.1.1.10.20.9.1SECTION 423.1000
     423.1000 Basis and scope.
42:3.0.1.1.10.20.9.2SECTION 423.1002
     423.1002 Definitions.
42:3.0.1.1.10.20.9.3SECTION 423.1004
     423.1004 Scope and applicability.
42:3.0.1.1.10.20.9.4SECTION 423.1006
     423.1006 Appeal rights.
42:3.0.1.1.10.20.9.5SECTION 423.1008
     423.1008 Appointment of representatives.
42:3.0.1.1.10.20.9.6SECTION 423.1010
     423.1010 Authority of representatives.
42:3.0.1.1.10.20.9.7SECTION 423.1012
     423.1012 Fees for services of representatives.
42:3.0.1.1.10.20.9.8SECTION 423.1014
     423.1014 Charge for transcripts.
42:3.0.1.1.10.20.9.9SECTION 423.1016
     423.1016 Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
42:3.0.1.1.10.20.9.10SECTION 423.1018
     423.1018 Notice and effect of initial determinations.
42:3.0.1.1.10.20.9.11SECTION 423.1020
     423.1020 Request for hearing.
42:3.0.1.1.10.20.9.12SECTION 423.1022
     423.1022 Parties to the hearing.
42:3.0.1.1.10.20.9.13SECTION 423.1024
     423.1024 Designation of hearing official.
42:3.0.1.1.10.20.9.14SECTION 423.1026
     423.1026 Disqualification of Administrative Law Judge.
42:3.0.1.1.10.20.9.15SECTION 423.1028
     423.1028 Prehearing conference.
42:3.0.1.1.10.20.9.16SECTION 423.1030
     423.1030 Notice of prehearing conference.
42:3.0.1.1.10.20.9.17SECTION 423.1032
     423.1032 Conduct of prehearing conference.
42:3.0.1.1.10.20.9.18SECTION 423.1034
     423.1034 Record, order, and effect of prehearing conference.
42:3.0.1.1.10.20.9.19SECTION 423.1036
     423.1036 Time and place of hearing.
42:3.0.1.1.10.20.9.20SECTION 423.1038
     423.1038 Change in time and place of hearing.
42:3.0.1.1.10.20.9.21SECTION 423.1040
     423.1040 Joint hearings.
42:3.0.1.1.10.20.9.22SECTION 423.1042
     423.1042 Hearing on new issues.
42:3.0.1.1.10.20.9.23SECTION 423.1044
     423.1044 Subpoenas.
42:3.0.1.1.10.20.9.24SECTION 423.1046
     423.1046 Conduct of hearing.
42:3.0.1.1.10.20.9.25SECTION 423.1048
     423.1048 Evidence.
42:3.0.1.1.10.20.9.26SECTION 423.1050
     423.1050 Witnesses.
42:3.0.1.1.10.20.9.27SECTION 423.1052
     423.1052 Oral and written summation.
42:3.0.1.1.10.20.9.28SECTION 423.1054
     423.1054 Record of hearing.
42:3.0.1.1.10.20.9.29SECTION 423.1056
     423.1056 Waiver of right to appear and present evidence.
42:3.0.1.1.10.20.9.30SECTION 423.1058
     423.1058 Dismissal of request for hearing.
42:3.0.1.1.10.20.9.31SECTION 423.1060
     423.1060 Dismissal for abandonment.
42:3.0.1.1.10.20.9.32SECTION 423.1062
     423.1062 Dismissal for cause.
42:3.0.1.1.10.20.9.33SECTION 423.1064
     423.1064 Notice and effect of dismissal and right to request review.
42:3.0.1.1.10.20.9.34SECTION 423.1066
     423.1066 Vacating a dismissal of request for hearing.
42:3.0.1.1.10.20.9.35SECTION 423.1068
     423.1068 Administrative Law Judge's decision.
42:3.0.1.1.10.20.9.36SECTION 423.1070
     423.1070 Removal of hearing to Departmental Appeals Board.
42:3.0.1.1.10.20.9.37SECTION 423.1072
     423.1072 Remand by the Administrative Law Judge.
42:3.0.1.1.10.20.9.38SECTION 423.1074
     423.1074 Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
42:3.0.1.1.10.20.9.39SECTION 423.1076
     423.1076 Request for Departmental Appeals Board review.
42:3.0.1.1.10.20.9.40SECTION 423.1078
     423.1078 Departmental Appeals Board action on request for review.
42:3.0.1.1.10.20.9.41SECTION 423.1080
     423.1080 Procedures before the Departmental Appeals Board on review.
42:3.0.1.1.10.20.9.42SECTION 423.1082
     423.1082 Evidence admissible on review.
42:3.0.1.1.10.20.9.43SECTION 423.1084
     423.1084 Decision or remand by the Departmental Appeals Board.
42:3.0.1.1.10.20.9.44SECTION 423.1086
     423.1086 Effect of Departmental Appeals Board Decision.
42:3.0.1.1.10.20.9.45SECTION 423.1088
     423.1088 Extension of time for seeking judicial review.
42:3.0.1.1.10.20.9.46SECTION 423.1090
     423.1090 Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
42:3.0.1.1.10.20.9.47SECTION 423.1092
     423.1092 Revision of reopened decision.
42:3.0.1.1.10.20.9.48SECTION 423.1094
     423.1094 Notice and effect of revised decision.
42:3.0.1.1.10.21SUBPART U
Subpart U - Reopening, ALJ Hearings and ALJ and Attorney Adjudicator Decisions, Council Review, and Judicial Review
42:3.0.1.1.10.21.9.1SECTION 423.1968
     423.1968 Scope.
42:3.0.1.1.10.21.9.2SECTION 423.1970-423.1976
     423.1970-423.1976 [Reserved]
42:3.0.1.1.10.21.9.3SECTION 423.1978
     423.1978 Reopening determinations and decisions.
42:3.0.1.1.10.21.9.4SECTION 423.1980
     423.1980 Reopening of coverage determinations, redeterminations, reconsiderations, decisions, and reviews.
42:3.0.1.1.10.21.9.5SECTION 423.1982
     423.1982 Notice of a revised determination or decision.
42:3.0.1.1.10.21.9.6SECTION 423.1984
     423.1984 Effect of a revised determination or decision.
42:3.0.1.1.10.21.9.7SECTION 423.1986
     423.1986 Good cause for reopening.
42:3.0.1.1.10.21.9.8SECTION 423.1990
     423.1990 Expedited access to judicial review.
42:3.0.1.1.10.21.9.9SECTION 423.2000
     423.2000 Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
42:3.0.1.1.10.21.9.10SECTION 423.2002
     423.2002 Right to an ALJ hearing.
42:3.0.1.1.10.21.9.11SECTION 423.2004
     423.2004 Right to a review of IRE notice of dismissal.
42:3.0.1.1.10.21.9.12SECTION 423.2006
     423.2006 Amount in controversy required for an ALJ hearing and judicial review.
42:3.0.1.1.10.21.9.13SECTION 423.2008
     423.2008 Parties to the proceedings on a request for an ALJ hearing.
42:3.0.1.1.10.21.9.14SECTION 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.
42:3.0.1.1.10.21.9.15SECTION 423.2014
     423.2014 Request for an ALJ hearing or a review of an IRE dismissal.
42:3.0.1.1.10.21.9.16SECTION 423.2016
     423.2016 Timeframes for deciding an appeal of an IRE reconsideration.
42:3.0.1.1.10.21.9.17SECTION 423.2018
     423.2018 Submitting evidence.
42:3.0.1.1.10.21.9.18SECTION 423.2020
     423.2020 Time and place for a hearing before an ALJ.
42:3.0.1.1.10.21.9.19SECTION 423.2022
     423.2022 Notice of a hearing before an ALJ.
42:3.0.1.1.10.21.9.20SECTION 423.2024
     423.2024 Objections to the issues.
42:3.0.1.1.10.21.9.21SECTION 423.2026
     423.2026 Disqualification of the ALJ or attorney adjudicator.
42:3.0.1.1.10.21.9.22SECTION 423.2030
     423.2030 ALJ hearing procedures.
42:3.0.1.1.10.21.9.23SECTION 423.2032
     423.2032 Issues before an ALJ or attorney adjudicator.
42:3.0.1.1.10.21.9.24SECTION 423.2034
     423.2034 Requesting information from the IRE.
42:3.0.1.1.10.21.9.25SECTION 423.2036
     423.2036 Description of an ALJ hearing process.
42:3.0.1.1.10.21.9.26SECTION 423.2038
     423.2038 Deciding a case without a hearing before an ALJ.
42:3.0.1.1.10.21.9.27SECTION 423.2040
     423.2040 Prehearing and posthearing conferences.
42:3.0.1.1.10.21.9.28SECTION 423.2042
     423.2042 The administrative record.
42:3.0.1.1.10.21.9.29SECTION 423.2044
     423.2044 Consolidated proceedings.
42:3.0.1.1.10.21.9.30SECTION 423.2046
     423.2046 Notice of an ALJ or attorney adjudicator decision.
42:3.0.1.1.10.21.9.31SECTION 423.2048
     423.2048 The effect of an ALJ's or attorney adjudicator's decision.
42:3.0.1.1.10.21.9.32SECTION 423.2050
     423.2050 Removal of a hearing request from OMHA to the Council.
42:3.0.1.1.10.21.9.33SECTION 423.2052
     423.2052 Dismissal of a request for a hearing before an ALJ or request for review of an IRE dismissal.
42:3.0.1.1.10.21.9.34SECTION 423.2054
     423.2054 Effect of dismissal of a request for a hearing or request for review of an IRE's dismissal.
42:3.0.1.1.10.21.9.35SECTION 423.2056
     423.2056 Remands of requests for hearing and requests for review.
42:3.0.1.1.10.21.9.36SECTION 423.2058
     423.2058 Effect of a remand.
42:3.0.1.1.10.21.9.37SECTION 423.2062
     423.2062 Applicability of policies not binding on the ALJ and Council.
42:3.0.1.1.10.21.9.38SECTION 423.2063
     423.2063 Applicability of laws, regulations, CMS Rulings, and precedential decisions.
42:3.0.1.1.10.21.9.39SECTION 423.2100
     423.2100 Medicare Appeals Council review: general.
42:3.0.1.1.10.21.9.40SECTION 423.2102
     423.2102 Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
42:3.0.1.1.10.21.9.41SECTION 423.2106
     423.2106 Where a request for review may be filed.
42:3.0.1.1.10.21.9.42SECTION 423.2108
     423.2108 Council Actions when request for review is filed.
42:3.0.1.1.10.21.9.43SECTION 423.2110
     423.2110 Council reviews on its own motion.
42:3.0.1.1.10.21.9.44SECTION 423.2112
     423.2112 Content of request for review.
42:3.0.1.1.10.21.9.45SECTION 423.2114
     423.2114 Dismissal of request for review.
42:3.0.1.1.10.21.9.46SECTION 423.2116
     423.2116 Effect of dismissal of request for Council review or request for hearing.
42:3.0.1.1.10.21.9.47SECTION 423.2118
     423.2118 Obtaining evidence from the Council.
42:3.0.1.1.10.21.9.48SECTION 423.2120
     423.2120 Filing briefs with the Council.
42:3.0.1.1.10.21.9.49SECTION 423.2122
     423.2122 What evidence may be submitted to the Council.
42:3.0.1.1.10.21.9.50SECTION 423.2124
     423.2124 Oral argument.
42:3.0.1.1.10.21.9.51SECTION 423.2126
     423.2126 Case remanded by the Council.
42:3.0.1.1.10.21.9.52SECTION 423.2128
     423.2128 Action of the Council.
42:3.0.1.1.10.21.9.53SECTION 423.2130
     423.2130 Effect of the Council's decision.
42:3.0.1.1.10.21.9.54SECTION 423.2134
     423.2134 Extension of time to file action in Federal District Court.
42:3.0.1.1.10.21.9.55SECTION 423.2136
     423.2136 Judicial review.
42:3.0.1.1.10.21.9.56SECTION 423.2138
     423.2138 Case remanded by a Federal District Court.
42:3.0.1.1.10.21.9.57SECTION 423.2140
     423.2140 Council Review of ALJ or attorney adjudicator decision in a case remanded by a Federal District Court.
42:3.0.1.1.10.22SUBPART V
Subpart V - Part D Communication Requirements
42:3.0.1.1.10.22.9.1SECTION 423.2260
     423.2260 Definitions.
42:3.0.1.1.10.22.9.2SECTION 423.2262
     423.2262 Review and distribution of marketing materials.
42:3.0.1.1.10.22.9.3SECTION 423.2264
     423.2264 Guidelines for CMS review.
42:3.0.1.1.10.22.9.4SECTION 423.2266
     423.2266 [Reserved]
42:3.0.1.1.10.22.9.5SECTION 423.2268
     423.2268 Standards for Part D Sponsor communications and marketing.
42:3.0.1.1.10.22.9.6SECTION 423.2272
     423.2272 Licensing of marketing representatives and confirmation of marketing resources.
42:3.0.1.1.10.22.9.7SECTION 423.2274
     423.2274 Broker and agent requirements.
42:3.0.1.1.10.22.9.8SECTION 423.2276
     423.2276 Employer group retiree marketing.
42:3.0.1.1.10.23SUBPART W
Subpart W - Medicare Coverage Gap Discount Program
42:3.0.1.1.10.23.9.1SECTION 423.2300
     423.2300 Scope.
42:3.0.1.1.10.23.9.2SECTION 423.2305
     423.2305 Definitions.
42:3.0.1.1.10.23.9.3SECTION 423.2310
     423.2310 Condition for coverage of drugs under Part D.
42:3.0.1.1.10.23.9.4SECTION 423.2315
     423.2315 Medicare Coverage Gap Discount Program Agreement.
42:3.0.1.1.10.23.9.5SECTION 423.2320
     423.2320 Payment processes for Part D sponsors.
42:3.0.1.1.10.23.9.6SECTION 423.2325
     423.2325 Provision of applicable discounts.
42:3.0.1.1.10.23.9.7SECTION 423.2330
     423.2330 Manufacturer discount payment audit and dispute resolution.
42:3.0.1.1.10.23.9.8SECTION 423.2335
     423.2335 Beneficiary dispute resolution.
42:3.0.1.1.10.23.9.9SECTION 423.2340
     423.2340 Compliance monitoring and civil money penalties.
42:3.0.1.1.10.23.9.10SECTION 423.2345
     423.2345 Termination of Discount Program Agreement.
42:3.0.1.1.10.24SUBPART X
Subpart X - Requirements for a Minimum Medical Loss Ratio
42:3.0.1.1.10.24.9.1SECTION 423.2400
     423.2400 Basis and scope.
42:3.0.1.1.10.24.9.2SECTION 423.2401
     423.2401 Definitions.
42:3.0.1.1.10.24.9.3SECTION 423.2410
     423.2410 General requirements.
42:3.0.1.1.10.24.9.4SECTION 423.2420
     423.2420 Calculation of medical loss ratio.
42:3.0.1.1.10.24.9.5SECTION 423.2430
     423.2430 Activities that improve health care quality.
42:3.0.1.1.10.24.9.6SECTION 423.2440
     423.2440 Credibility adjustment.
42:3.0.1.1.10.24.9.7SECTION 423.2450
     423.2450 [Reserved]
42:3.0.1.1.10.24.9.8SECTION 423.2460
     423.2460 Reporting requirements.
42:3.0.1.1.10.24.9.9SECTION 423.2470
     423.2470 Remittance to CMS if the applicable MLR requirement is not met.
42:3.0.1.1.10.24.9.10SECTION 423.2480
     423.2480 MLR review and non-compliance.
42:3.0.1.1.10.24.9.11SECTION 423.2490
     423.2490 Release of Part D MLR data.
42:3.0.1.1.10.25SUBPART Y
Subpart Y [Reserved]
42:3.0.1.1.10.26SUBPART Z
Subpart Z - Recovery Audit Contractor Part C Appeals Process
42:3.0.1.1.10.26.9.1SECTION 423.2600
     423.2600 Payment appeals.
42:3.0.1.1.10.26.9.2SECTION 423.2605
     423.2605 Request for reconsideration.
42:3.0.1.1.10.26.9.3SECTION 423.2610
     423.2610 Hearing official review.
42:3.0.1.1.10.26.9.4SECTION 423.2615
     423.2615 Review by the Administrator.
42:3.0.1.1.11PART 424
PART 424 - CONDITIONS FOR MEDICARE PAYMENT
42:3.0.1.1.11.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.11.1.9.1SECTION 424.1
     424.1 Basis and scope.
42:3.0.1.1.11.1.9.2SECTION 424.3
     424.3 Definitions.
42:3.0.1.1.11.1.9.3SECTION 424.5
     424.5 Basic conditions.
42:3.0.1.1.11.1.9.4SECTION 424.7
     424.7 General limitations.
42:3.0.1.1.11.2SUBPART B
Subpart B - Certification and Plan Requirements
42:3.0.1.1.11.2.9.1SECTION 424.10
     424.10 Purpose and scope.
42:3.0.1.1.11.2.9.2SECTION 424.11
     424.11 General procedures.
42:3.0.1.1.11.2.9.3SECTION 424.13
     424.13 Requirements for inpatient services of hospitals other than inpatient psychiatric facilities.
42:3.0.1.1.11.2.9.4SECTION 424.14
     424.14 Requirements for inpatient services of inpatient psychiatric facilities.
42:3.0.1.1.11.2.9.5SECTION 424.15
     424.15 Requirements for inpatient CAH services.
42:3.0.1.1.11.2.9.6SECTION 424.16
     424.16 Timing of certification for individual admitted to a hospital before entitlement to Medicare benefits.
42:3.0.1.1.11.2.9.7SECTION 424.20
     424.20 Requirements for posthospital SNF care.
42:3.0.1.1.11.2.9.8SECTION 424.22
     424.22 Requirements for home health services.
42:3.0.1.1.11.2.9.9SECTION 424.24
     424.24 Requirements for medical and other health services furnished by providers under Medicare Part B.
42:3.0.1.1.11.2.9.10SECTION 424.27
     424.27 Requirements for comprehensive outpatient rehabilitation facility (CORF) services.
42:3.0.1.1.11.3SUBPART C
Subpart C - Claims for Payment
42:3.0.1.1.11.3.9.1SECTION 424.30
     424.30 Scope.
42:3.0.1.1.11.3.9.2SECTION 424.32
     424.32 Basic requirements for all claims.
42:3.0.1.1.11.3.9.3SECTION 424.33
     424.33 Additional requirements: Claims for services of providers and claims by suppliers and nonparticipating hospitals.
42:3.0.1.1.11.3.9.4SECTION 424.34
     424.34 Additional requirements: Beneficiary's claim for direct payment.
42:3.0.1.1.11.3.9.5SECTION 424.36
     424.36 Signature requirements.
42:3.0.1.1.11.3.9.6SECTION 424.37
     424.37 Evidence of authority to sign on behalf of the beneficiary.
42:3.0.1.1.11.3.9.7SECTION 424.40
     424.40 Request for payment effective for more than one claim.
42:3.0.1.1.11.3.9.8SECTION 424.44
     424.44 Time limits for filing claims.
42:3.0.1.1.11.4SUBPART D
Subpart D - To Whom Payment Is Ordinarily Made
42:3.0.1.1.11.4.9.1SECTION 424.50
     424.50 Scope.
42:3.0.1.1.11.4.9.2SECTION 424.51
     424.51 Payment to the provider.
42:3.0.1.1.11.4.9.3SECTION 424.52
     424.52 Payment to a nonparticipating hospital.
42:3.0.1.1.11.4.9.4SECTION 424.53
     424.53 Payment to the beneficiary.
42:3.0.1.1.11.4.9.5SECTION 424.54
     424.54 Payment to the beneficiary's legal guardian or representative payee.
42:3.0.1.1.11.4.9.6SECTION 424.55
     424.55 Payment to the supplier.
42:3.0.1.1.11.4.9.7SECTION 424.56
     424.56 Payment to a beneficiary and to a supplier.
42:3.0.1.1.11.4.9.8SECTION 424.57
     424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.
42:3.0.1.1.11.4.9.9SECTION 424.58
     424.58 Accreditation.
42:3.0.1.1.11.5SUBPART E
Subpart E - To Whom Payment is Made in Special Situations
42:3.0.1.1.11.5.9.1SECTION 424.60
     424.60 Scope.
42:3.0.1.1.11.5.9.2SECTION 424.62
     424.62 Payment after beneficiary's death: Bill has been paid.
42:3.0.1.1.11.5.9.3SECTION 424.64
     424.64 Payment after beneficiary's death: Bill has not been paid.
42:3.0.1.1.11.5.9.4SECTION 424.66
     424.66 Payment to entities that provide coverage complementary to Medicare Part B.
42:3.0.1.1.11.5.9.5SECTION 424.67
     424.67 Enrollment requirements for opioid treatment programs (OTP).
42:3.0.1.1.11.6SUBPART F
Subpart F - Limitations on Assignment and Reassignment of Claims
42:3.0.1.1.11.6.9.1SECTION 424.70
     424.70 Basis and scope.
42:3.0.1.1.11.6.9.2SECTION 424.71
     424.71 Definitions.
42:3.0.1.1.11.6.9.3SECTION 424.73
     424.73 Prohibition of assignment of claims by providers.
42:3.0.1.1.11.6.9.4SECTION 424.74
     424.74 Termination of provider agreement.
42:3.0.1.1.11.6.9.5SECTION 424.80
     424.80 Prohibition of reassignment of claims by suppliers.
42:3.0.1.1.11.6.9.6SECTION 424.82
     424.82 Revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.9.7SECTION 424.83
     424.83 Hearings on revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.9.8SECTION 424.84
     424.84 Final determination on revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.9.9SECTION 424.86
     424.86 Prohibition of assignment of claims by beneficiaries.
42:3.0.1.1.11.6.9.10SECTION 424.90
     424.90 Court ordered assignments: Conditions and limitations.
42:3.0.1.1.11.7SUBPART G
Subpart G - Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital
42:3.0.1.1.11.7.9.1SECTION 424.100
     424.100 Scope.
42:3.0.1.1.11.7.9.2SECTION 424.101
     424.101 Definitions.
42:3.0.1.1.11.7.9.3SECTION 424.102
     424.102 Situations that do not constitute an emergency.
42:3.0.1.1.11.7.9.4SECTION 424.103
     424.103 Conditions for payment for emergency services.
42:3.0.1.1.11.7.9.5SECTION 424.104
     424.104 Election to claim payment for emergency services furnished during a calendar year.
42:3.0.1.1.11.7.9.6SECTION 424.106
     424.106 Criteria for determining whether the hospital was the most accessible.
42:3.0.1.1.11.7.9.7SECTION 424.108
     424.108 Payment to a hospital.
42:3.0.1.1.11.7.9.8SECTION 424.109
     424.109 Payment to the beneficiary.
42:3.0.1.1.11.8SUBPART H
Subpart H - Special Conditions: Services Furnished in a Foreign Country
42:3.0.1.1.11.8.9.1SECTION 424.120
     424.120 Scope.
42:3.0.1.1.11.8.9.2SECTION 424.121
     424.121 Scope of payments.
42:3.0.1.1.11.8.9.3SECTION 424.122
     424.122 Conditions for payment for emergency inpatient hospital services.
42:3.0.1.1.11.8.9.4SECTION 424.123
     424.123 Conditions for payment for nonemergency inpatient services furnished by a hospital closer to the individual's residence.
42:3.0.1.1.11.8.9.5SECTION 424.124
     424.124 Conditions for payment for physician services and ambulance services.
42:3.0.1.1.11.8.9.6SECTION 424.126
     424.126 Payment to the hospital.
42:3.0.1.1.11.8.9.7SECTION 424.127
     424.127 Payment to the beneficiary.
42:3.0.1.1.11.9SUBPART I
Subpart I - Requirements for Medicare Diabetes Prevention Program Suppliers and Beneficiary Engagement Incentives Under the Medicare Diabetes Prevention Program Expanded Model
42:3.0.1.1.11.9.9.1SECTION 424.200
     424.200 Scope.
42:3.0.1.1.11.9.9.2SECTION 424.205
     424.205 Requirements for Medicare Diabetes Prevention Program suppliers.
42:3.0.1.1.11.9.9.3SECTION 424.210
     424.210 Beneficiary engagement incentives under the Medicare Diabetes Prevention Program expanded model.
42:3.0.1.1.11.10SUBPART J
Subparts J-L [Reserved]
42:3.0.1.1.11.11SUBPART M
Subpart M - Replacement and Reclamation of Medicare Payments
42:3.0.1.1.11.11.9.1SECTION 424.350
     424.350 Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.
42:3.0.1.1.11.11.9.2SECTION 424.352
     424.352 Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements.
42:3.0.1.1.11.12SUBPART N
Subparts N-O [Reserved]
42:3.0.1.1.11.13SUBPART P
Subpart P - Requirements for Establishing and Maintaining Medicare Billing Privileges
42:3.0.1.1.11.13.9.1SECTION 424.500
     424.500 Scope.
42:3.0.1.1.11.13.9.2SECTION 424.502
     424.502 Definitions.
42:3.0.1.1.11.13.9.3SECTION 424.505
     424.505 Basic enrollment requirement.
42:3.0.1.1.11.13.9.4SECTION 424.506
     424.506 National Provider Identifier (NPI) on all enrollment applications and claims.
42:3.0.1.1.11.13.9.5SECTION 424.507
     424.507 Ordering covered items and services for Medicare beneficiaries.
42:3.0.1.1.11.13.9.6SECTION 424.510
     424.510 Requirements for enrolling in the Medicare program.
42:3.0.1.1.11.13.9.7SECTION 424.514
     424.514 Application fee.
42:3.0.1.1.11.13.9.8SECTION 424.515
     424.515 Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.
42:3.0.1.1.11.13.9.9SECTION 424.516
     424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
42:3.0.1.1.11.13.9.10SECTION 424.517
     424.517 Onsite review.
42:3.0.1.1.11.13.9.11SECTION 424.518
     424.518 Screening levels for Medicare providers and suppliers.
42:3.0.1.1.11.13.9.12SECTION 424.519
     424.519 Disclosure of affiliations.
42:3.0.1.1.11.13.9.13SECTION 424.520
     424.520 Effective date of Medicare billing privileges.
42:3.0.1.1.11.13.9.14SECTION 424.521
     424.521 Request for payment by physicians, non-physician practitioners, physician and non-physician organizations, ambulance suppliers, and opioid treatment programs.
42:3.0.1.1.11.13.9.15SECTION 424.525
     424.525 Rejection of a provider or supplier's enrollment application for Medicare enrollment.
42:3.0.1.1.11.13.9.16SECTION 424.530
     424.530 Denial of enrollment in the Medicare program.
42:3.0.1.1.11.13.9.17SECTION 424.535
     424.535 Revocation of enrollment in the Medicare program.
42:3.0.1.1.11.13.9.18SECTION 424.540
     424.540 Deactivation of Medicare billing privileges.
42:3.0.1.1.11.13.9.19SECTION 424.545
     424.545 Provider and supplier appeal rights.
42:3.0.1.1.11.13.9.20SECTION 424.550
     424.550 Prohibitions on the sale or transfer of billing privileges.
42:3.0.1.1.11.13.9.21SECTION 424.555
     424.555 Payment liability.
42:3.0.1.1.11.13.9.22SECTION 424.565
     424.565 Overpayment.
42:3.0.1.1.11.13.9.23SECTION 424.570
     424.570 Moratoria on newly enrolling Medicare providers and suppliers.
42:3.0.1.1.12PART 425
PART 425 - MEDICARE SHARED SAVINGS PROGRAM
42:3.0.1.1.12.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.12.1.9.1SECTION 425.10
     425.10 Basis and scope.
42:3.0.1.1.12.1.9.2SECTION 425.20
     425.20 Definitions.
42:3.0.1.1.12.2SUBPART B
Subpart B - Shared Savings Program Eligibility Requirements
42:3.0.1.1.12.2.9.1SECTION 425.100
     425.100 General.
42:3.0.1.1.12.2.9.2SECTION 425.102
     425.102 Eligible providers and suppliers.
42:3.0.1.1.12.2.9.3SECTION 425.104
     425.104 Legal entity.
42:3.0.1.1.12.2.9.4SECTION 425.106
     425.106 Shared governance.
42:3.0.1.1.12.2.9.5SECTION 425.108
     425.108 Leadership and management.
42:3.0.1.1.12.2.9.6SECTION 425.110
     425.110 Number of ACO professionals and beneficiaries.
42:3.0.1.1.12.2.9.7SECTION 425.112
     425.112 Required processes and patient-centeredness criteria.
42:3.0.1.1.12.2.9.8SECTION 425.114
     425.114 Participation in other shared savings initiatives.
42:3.0.1.1.12.2.9.9SECTION 425.116
     425.116 Agreements with ACO participants and ACO providers/suppliers.
42:3.0.1.1.12.2.9.10SECTION 425.118
     425.118 Required reporting of ACO participants and ACO providers/suppliers.
42:3.0.1.1.12.3SUBPART C
Subpart C - Application Procedures and Participation Agreement
42:3.0.1.1.12.3.9.1SECTION 425.200
     425.200 Participation agreement with CMS.
42:3.0.1.1.12.3.9.2SECTION 425.202
     425.202 Application procedures.
42:3.0.1.1.12.3.9.3SECTION 425.204
     425.204 Content of the application.
42:3.0.1.1.12.3.9.4SECTION 425.206
     425.206 Evaluation procedures for applications.
42:3.0.1.1.12.3.9.5SECTION 425.208
     425.208 Provisions of participation agreement.
42:3.0.1.1.12.3.9.6SECTION 425.210
     425.210 Application of agreement to ACO participants, ACO providers/suppliers, and others.
42:3.0.1.1.12.3.9.7SECTION 425.212
     425.212 Changes to program requirements during the agreement period.
42:3.0.1.1.12.3.9.8SECTION 425.214
     425.214 Managing changes to the ACO during the agreement period.
42:3.0.1.1.12.3.9.9SECTION 425.216
     425.216 Actions prior to termination.
42:3.0.1.1.12.3.9.10SECTION 425.218
     425.218 Termination of the participation agreement by CMS.
42:3.0.1.1.12.3.9.11SECTION 425.220
     425.220 Termination of the participation agreement by the ACO.
42:3.0.1.1.12.3.9.12SECTION 425.221
     425.221 Close-out procedures and payment consequences of early termination.
42:3.0.1.1.12.3.9.13SECTION 425.222
     425.222 Eligibility to re-enter the program for agreement periods beginning before July 1, 2019.
42:3.0.1.1.12.3.9.14SECTION 425.224
     425.224 Application procedures for renewing ACOs and re-entering ACOs.
42:3.0.1.1.12.3.9.15SECTION 425.226
     425.226 Annual participation elections.
42:3.0.1.1.12.4SUBPART D
Subpart D - Program Requirements and Beneficiary Protections
42:3.0.1.1.12.4.9.1SECTION 425.300
     425.300 Compliance plan.
42:3.0.1.1.12.4.9.2SECTION 425.302
     425.302 Program requirements for data submission and certifications.
42:3.0.1.1.12.4.9.3SECTION 425.304
     425.304 Beneficiary incentives.
42:3.0.1.1.12.4.9.4SECTION 425.305
     425.305 Other program safeguards.
42:3.0.1.1.12.4.9.5SECTION 425.306
     425.306 Participant agreement and exclusivity of ACO participants.
42:3.0.1.1.12.4.9.6SECTION 425.308
     425.308 Public reporting and transparency.
42:3.0.1.1.12.4.9.7SECTION 425.310
     425.310 Marketing requirements.
42:3.0.1.1.12.4.9.8SECTION 425.312
     425.312 Beneficiary notifications.
42:3.0.1.1.12.4.9.9SECTION 425.314
     425.314 Audits and record retention.
42:3.0.1.1.12.4.9.10SECTION 425.315
     425.315 Reopening determinations of ACO shared savings or shared losses to correct financial reconciliation calculations.
42:3.0.1.1.12.4.9.11SECTION 425.316
     425.316 Monitoring of ACOs.
42:3.0.1.1.12.5SUBPART E
Subpart E - Assignment of Beneficiaries
42:3.0.1.1.12.5.9.1SECTION 425.400
     425.400 General.
42:3.0.1.1.12.5.9.2SECTION 425.401
     425.401 Criteria for a beneficiary to be assigned to an ACO.
42:3.0.1.1.12.5.9.3SECTION 425.402
     425.402 Basic assignment methodology.
42:3.0.1.1.12.5.9.4SECTION 425.404
     425.404 Special assignment conditions for ACOs including FQHCs and RHCs.
42:3.0.1.1.12.6SUBPART F
Subpart F - Quality Performance Standards and Reporting
42:3.0.1.1.12.6.9.1SECTION 425.500
     425.500 Measures to assess the quality of care furnished by an ACO.
42:3.0.1.1.12.6.9.2SECTION 425.502
     425.502 Calculating the ACO quality performance score.
42:3.0.1.1.12.6.9.3SECTION 425.504
     425.504 Incorporating reporting requirements related to the Physician Quality Reporting System Incentive and Payment Adjustment.
42:3.0.1.1.12.6.9.4SECTION 425.506
     425.506 Incorporating reporting requirements related to adoption of certified electronic health record technology.
42:3.0.1.1.12.6.9.5SECTION 425.508
     425.508 Incorporating quality reporting requirements related to the Quality Payment Program.
42:3.0.1.1.12.7SUBPART G
Subpart G - Shared Savings and Losses
42:3.0.1.1.12.7.9.1SECTION 425.600
     425.600 Selection of risk model.
42:3.0.1.1.12.7.9.2SECTION 425.601
     425.601 Establishing, adjusting, and updating the benchmark for agreement periods beginning on July 1, 2019, and in subsequent years.
42:3.0.1.1.12.7.9.3SECTION 425.602
     425.602 Establishing, adjusting, and updating the benchmark for an ACO's first agreement period beginning on or before January 1, 2018.
42:3.0.1.1.12.7.9.4SECTION 425.603
     425.603 Resetting, adjusting, and updating the benchmark for a subsequent agreement period beginning on or before January 1, 2019.
42:3.0.1.1.12.7.9.5SECTION 425.604
     425.604 Calculation of savings under the one-sided model.
42:3.0.1.1.12.7.9.6SECTION 425.605
     425.605 Calculation of shared savings and losses under the BASIC track.
42:3.0.1.1.12.7.9.7SECTION 425.606
     425.606 Calculation of shared savings and losses under Track 2.
42:3.0.1.1.12.7.9.8SECTION 425.608
     425.608 Determining first year performance for ACOs beginning April 1 or July 1, 2012.
42:3.0.1.1.12.7.9.9SECTION 425.609
     425.609 Determining performance for 6-month performance years during CY 2019.
42:3.0.1.1.12.7.9.10SECTION 425.610
     425.610 Calculation of shared savings and losses under the ENHANCED track.
42:3.0.1.1.12.7.9.11SECTION 425.611
     425.611 Adjustments to Shared Savings Program calculations to address the COVID-19 pandemic.
42:3.0.1.1.12.7.9.12SECTION 425.612
     425.612 Waivers of payment rules or other Medicare requirements.
42:3.0.1.1.12.7.9.13SECTION 425.613
     425.613 Telehealth services.
42:3.0.1.1.12.8SUBPART H
Subpart H - Data Sharing With ACOs
42:3.0.1.1.12.8.9.1SECTION 425.700
     425.700 General rules.
42:3.0.1.1.12.8.9.2SECTION 425.702
     425.702 Aggregate reports.
42:3.0.1.1.12.8.9.3SECTION 425.704
     425.704 Beneficiary-identifiable claims data.
42:3.0.1.1.12.8.9.4SECTION 425.706
     425.706 Minimum necessary data.
42:3.0.1.1.12.8.9.5SECTION 425.708
     425.708 Beneficiaries may decline claims data sharing.
42:3.0.1.1.12.8.9.6SECTION 425.710
     425.710 Data use agreement.
42:3.0.1.1.12.9SUBPART I
Subpart I - Reconsideration Review Process
42:3.0.1.1.12.9.9.1SECTION 425.800
     425.800 Preclusion of administrative and judicial review.
42:3.0.1.1.12.9.9.2SECTION 425.802
     425.802 Request for review.
42:3.0.1.1.12.9.9.3SECTION 425.804
     425.804 Reconsideration review process.
42:3.0.1.1.12.9.9.4SECTION 425.806
     425.806 On-the-record review of reconsideration official's recommendation by independent CMS official.
42:3.0.1.1.12.9.9.5SECTION 425.808
     425.808 Effect of independent CMS official's decision.
42:3.0.1.1.12.9.9.6SECTION 425.810
     425.810 Effective date of decision.
42:3.0.1.1.13PART 426
PART 426 - REVIEW OF NATIONAL COVERAGE DETERMINATIONS AND LOCAL COVERAGE DETERMINATIONS
42:3.0.1.1.13.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.13.1.9.1SECTION 426.100
     426.100 Basis and scope.
42:3.0.1.1.13.1.9.2SECTION 426.110
     426.110 Definitions.
42:3.0.1.1.13.1.9.3SECTION 426.120
     426.120 Calculation of deadlines.
42:3.0.1.1.13.1.9.4SECTION 426.130
     426.130 Party submissions.
42:3.0.1.1.13.2SUBPART B
Subpart B [Reserved]
42:3.0.1.1.13.3SUBPART C
Subpart C - General Provisions for the Review of LCDs and NCDs
42:3.0.1.1.13.3.9.1SECTION 426.300
     426.300 Review of LCDs, NCDs, and deemed NCDs.
42:3.0.1.1.13.3.9.2SECTION 426.310
     426.310 LCD and NCD reviews and individual claim appeals.
42:3.0.1.1.13.3.9.3SECTION 426.320
     426.320 Who may challenge an LCD or NCD.
42:3.0.1.1.13.3.9.4SECTION 426.325
     426.325 What may be challenged.
42:3.0.1.1.13.3.9.5SECTION 426.330
     426.330 Burden of proof.
42:3.0.1.1.13.3.9.6SECTION 426.340
     426.340 Procedures for review of new evidence.
42:3.0.1.1.13.4SUBPART D
Subpart D - Review of an LCD
42:3.0.1.1.13.4.9.1SECTION 426.400
     426.400 Procedure for filing an acceptable complaint concerning a provision (or provisions) of an LCD.
42:3.0.1.1.13.4.9.2SECTION 426.403
     426.403 Submitting new evidence once an acceptable complaint is filed.
42:3.0.1.1.13.4.9.3SECTION 426.405
     426.405 Authority of the ALJ.
42:3.0.1.1.13.4.9.4SECTION 426.406
     426.406 Ex parte contacts.
42:3.0.1.1.13.4.9.5SECTION 426.410
     426.410 Docketing and evaluating the acceptability of LCD complaints.
42:3.0.1.1.13.4.9.6SECTION 426.415
     426.415 CMS' role in the LCD review.
42:3.0.1.1.13.4.9.7SECTION 426.416
     426.416 Role of Medicare Managed Care Organizations (MCOs) and State agencies in the LCD review.
42:3.0.1.1.13.4.9.8SECTION 426.417
     426.417 Contractor's statement regarding new evidence.
42:3.0.1.1.13.4.9.9SECTION 426.418
     426.418 LCD record furnished to aggrieved party.
42:3.0.1.1.13.4.9.10SECTION 426.419
     426.419 LCD record furnished to the ALJ.
42:3.0.1.1.13.4.9.11SECTION 426.420
     426.420 Retiring or revising an LCD under review.
42:3.0.1.1.13.4.9.12SECTION 426.423
     426.423 Withdrawing a complaint regarding an LCD under review.
42:3.0.1.1.13.4.9.13SECTION 426.425
     426.425 LCD review.
42:3.0.1.1.13.4.9.14SECTION 426.431
     426.431 ALJ's review of the LCD to apply the reasonableness standard.
42:3.0.1.1.13.4.9.15SECTION 426.432
     426.432 Discovery.
42:3.0.1.1.13.4.9.16SECTION 426.435
     426.435 Subpoenas.
42:3.0.1.1.13.4.9.17SECTION 426.440
     426.440 Evidence.
42:3.0.1.1.13.4.9.18SECTION 426.444
     426.444 Dismissals for cause.
42:3.0.1.1.13.4.9.19SECTION 426.445
     426.445 Witness fees.
42:3.0.1.1.13.4.9.20SECTION 426.446
     426.446 Record of hearing.
42:3.0.1.1.13.4.9.21SECTION 426.447
     426.447 Issuance and notification of an ALJ's decision.
42:3.0.1.1.13.4.9.22SECTION 426.450
     426.450 Mandatory provisions of an ALJ's decision.
42:3.0.1.1.13.4.9.23SECTION 426.455
     426.455 Prohibited provisions of an ALJ's decision.
42:3.0.1.1.13.4.9.24SECTION 426.457
     426.457 Optional provisions of an ALJ's decision.
42:3.0.1.1.13.4.9.25SECTION 426.458
     426.458 ALJ's LCD review record.
42:3.0.1.1.13.4.9.26SECTION 426.460
     426.460 Effect of an ALJ's decision.
42:3.0.1.1.13.4.9.27SECTION 426.462
     426.462 Notice of an ALJ's decision.
42:3.0.1.1.13.4.9.28SECTION 426.463
     426.463 Future new or revised LCDs.
42:3.0.1.1.13.4.9.29SECTION 426.465
     426.465 Appealing part or all of an ALJ's decision.
42:3.0.1.1.13.4.9.30SECTION 426.468
     426.468 Decision to not appeal an ALJ's decision.
42:3.0.1.1.13.4.9.31SECTION 426.470
     426.470 Board's role in docketing and evaluating the acceptability of appeals of ALJ decisions.
42:3.0.1.1.13.4.9.32SECTION 426.476
     426.476 Board review of an ALJ's decision.
42:3.0.1.1.13.4.9.33SECTION 426.478
     426.478 Retiring or revising an LCD during the Board's review of an ALJ's decision.
42:3.0.1.1.13.4.9.34SECTION 426.480
     426.480 Withdrawing an appeal of an ALJ's decision.
42:3.0.1.1.13.4.9.35SECTION 426.482
     426.482 Issuance and notification of a Board decision.
42:3.0.1.1.13.4.9.36SECTION 426.484
     426.484 Mandatory provisions of a Board decision.
42:3.0.1.1.13.4.9.37SECTION 426.486
     426.486 Prohibited provisions of a Board decision.
42:3.0.1.1.13.4.9.38SECTION 426.487
     426.487 Board's record on appeal of an ALJ's decision.
42:3.0.1.1.13.4.9.39SECTION 426.488
     426.488 Effect of a Board decision.
42:3.0.1.1.13.4.9.40SECTION 426.489
     426.489 Board remands.
42:3.0.1.1.13.4.9.41SECTION 426.490
     426.490 Board decision.
42:3.0.1.1.13.5SUBPART E
Subpart E - Review of an NCD
42:3.0.1.1.13.5.9.1SECTION 426.500
     426.500 Procedure for filing an acceptable complaint concerning a provision (or provisions) of an NCD.
42:3.0.1.1.13.5.9.2SECTION 426.503
     426.503 Submitting new evidence once an acceptable complaint has been filed.
42:3.0.1.1.13.5.9.3SECTION 426.505
     426.505 Authority of the Board.
42:3.0.1.1.13.5.9.4SECTION 426.506
     426.506 Ex parte contacts.
42:3.0.1.1.13.5.9.5SECTION 426.510
     426.510 Docketing and evaluating the acceptability of NCD complaints.
42:3.0.1.1.13.5.9.6SECTION 426.513
     426.513 Participation as amicus curiae.
42:3.0.1.1.13.5.9.7SECTION 426.515
     426.515 CMS' role in making the NCD record available.
42:3.0.1.1.13.5.9.8SECTION 426.516
     426.516 Role of Medicare Managed Care Organizations (MCOs) and State agencies in the NCD review process.
42:3.0.1.1.13.5.9.9SECTION 426.517
     426.517 CMS' statement regarding new evidence.
42:3.0.1.1.13.5.9.10SECTION 426.518
     426.518 NCD record furnished to the aggrieved party.
42:3.0.1.1.13.5.9.11SECTION 426.519
     426.519 NCD record furnished to the Board.
42:3.0.1.1.13.5.9.12SECTION 426.520
     426.520 Withdrawing an NCD under review or issuing a revised or reconsidered NCD.
42:3.0.1.1.13.5.9.13SECTION 426.523
     426.523 Withdrawing a complaint regarding an NCD under review.
42:3.0.1.1.13.5.9.14SECTION 426.525
     426.525 NCD review.
42:3.0.1.1.13.5.9.15SECTION 426.531
     426.531 Board's review of the NCD to apply the reasonableness standard.
42:3.0.1.1.13.5.9.16SECTION 426.532
     426.532 Discovery.
42:3.0.1.1.13.5.9.17SECTION 426.535
     426.535 Subpoenas.
42:3.0.1.1.13.5.9.18SECTION 426.540
     426.540 Evidence.
42:3.0.1.1.13.5.9.19SECTION 426.544
     426.544 Dismissals for cause.
42:3.0.1.1.13.5.9.20SECTION 426.545
     426.545 Witness fees.
42:3.0.1.1.13.5.9.21SECTION 426.546
     426.546 Record of hearing.
42:3.0.1.1.13.5.9.22SECTION 426.547
     426.547 Issuance, notification, and posting of a Board's decision.
42:3.0.1.1.13.5.9.23SECTION 426.550
     426.550 Mandatory provisions of the Board's decision.
42:3.0.1.1.13.5.9.24SECTION 426.555
     426.555 Prohibited provisions of the Board's decision.
42:3.0.1.1.13.5.9.25SECTION 426.557
     426.557 Optional provisions of the Board's decision.
42:3.0.1.1.13.5.9.26SECTION 426.560
     426.560 Effect of the Board's decision.
42:3.0.1.1.13.5.9.27SECTION 426.562
     426.562 Notice of the Board's decision.
42:3.0.1.1.13.5.9.28SECTION 426.563
     426.563 Future new or revised or reconsidered NCDs.
42:3.0.1.1.13.5.9.29SECTION 426.565
     426.565 Board's role in making an LCD or NCD review record available.
42:3.0.1.1.13.5.9.30SECTION 426.566
     426.566 Board decision.
42:3.0.1.1.13.5.9.31SECTION 426.587
     426.587 Record for appeal of a Board NCD decision.
42:3.0.1.1.14PART 427-429
PARTS 427-429 [RESERVED]