Subpart I. Subpart I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

• § 405.900 - Basis and scope.
• § 405.902 - Definitions.
• § 405.903 - Prepayment review.
• § 405.904 - Medicare initial determinations, redeterminations and appeals: General description.
• § 405.906 - Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.
• § 405.908 - Medicaid State agencies.
• § 405.910 - Appointed representatives.
• § 405.912 - Assignment of appeal rights.

• Initial Determinations

  • SECTION § 405.920 - Initial determinations.
  • SECTION § 405.921 - Notice of initial determination.
  • SECTION § 405.922 - Time frame for processing initial determinations.
  • SECTION § 405.924 - Actions that are initial determinations.
  • SECTION § 405.925 - Decisions of utilization review committees.
  • SECTION § 405.926 - Actions that are not initial determinations.
  • SECTION § 405.927 - Initial determinations subject to the reopenings process.
  • SECTION § 405.928 - Effect of the initial determination.
  • SECTION § 405.929 - Post-payment review.
  • SECTION § 405.930 - Failure to respond to additional documentation request.

• Retrospective Appeals for Changes in Patient Status That Resulted in Denial of Part A Coverage for Hospital Services

  • SECTION § 405.931 - Scope, basis, and definitions.
  • SECTION § 405.932 - Right to appeal a denial of Part A coverage resulting from a change in patient status.
  • SECTION § 405.934 - Reconsideration.
  • SECTION § 405.936 - Hearings before an ALJ and decisions by an ALJ or Attorney Adjudicator.
  • SECTION § 405.938 - Review by the Medicare Appeals Council and judicial review.

• Redeterminations

  • SECTION § 405.940 - Right to a redetermination.
  • SECTION § 405.942 - Time frame for filing a request for a redetermination.
  • SECTION § 405.944 - Place and method of filing a request for a redetermination.
  • SECTION § 405.946 - Evidence to be submitted with the redetermination request.
  • SECTION § 405.947 - Notice to the beneficiary of applicable plan's request for a redetermination.
  • SECTION § 405.948 - Conduct of a redetermination.
  • SECTION § 405.950 - Time frame for making a redetermination.
  • SECTION § 405.952 - Withdrawal or dismissal of a request for a redetermination.
  • SECTION § 405.954 - Redetermination.
  • SECTION § 405.956 - Notice of a redetermination.
  • SECTION § 405.958 - Effect of a redetermination.

• Reconsideration

  • SECTION § 405.960 - Right to a reconsideration.
  • SECTION § 405.962 - Timeframe for filing a request for a reconsideration.
  • SECTION § 405.964 - Place and method of filing a request for a reconsideration.
  • SECTION § 405.966 - Evidence to be submitted with the reconsideration request.
  • SECTION § 405.968 - Conduct of a reconsideration.
  • SECTION § 405.970 - Timeframe for making a reconsideration following a contractor redetermination.
  • SECTION § 405.972 - Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.
  • SECTION § 405.974 - Reconsideration and review of a contractor's dismissal of a request for redetermination.
  • SECTION § 405.976 - Notice of a reconsideration.
  • SECTION § 405.978 - Effect of a reconsideration.

• Reopenings

  • SECTION § 405.980 - Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.
  • SECTION § 405.982 - Notice of a revised determination or decision.
  • SECTION § 405.984 - Effect of a revised determination or decision.
  • SECTION § 405.986 - Good cause for reopening.

• Expedited Access to Judicial Review

  • SECTION § 405.990 - Expedited access to judicial review.

• ALJ Hearings

  • SECTION § 405.1000 - Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.
  • SECTION § 405.1002 - Right to an ALJ hearing.
  • SECTION § 405.1004 - Right to a review of QIC notice of dismissal.
  • SECTION § 405.1006 - Amount in controversy required for an ALJ hearing and judicial review.
  • SECTION § 405.1008 - Parties to the proceedings on a request for an ALJ hearing.
  • SECTION § 405.1010 - When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.
  • SECTION § 405.1012 - When CMS or its contractors may be a party to a hearing.
  • SECTION § 405.1014 - Request for an ALJ hearing or a review of a QIC dismissal.
  • SECTION § 405.1016 - Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.
  • SECTION § 405.1018 - Submitting evidence.
  • SECTION § 405.1020 - Time and place for a hearing before an ALJ.
  • SECTION § 405.1022 - Notice of a hearing before an ALJ.
  • SECTION § 405.1024 - Objections to the issues.
  • SECTION § 405.1026 - Disqualification of the ALJ or attorney adjudicator.
  • SECTION § 405.1028 - Review of evidence submitted by parties.
  • SECTION § 405.1030 - ALJ hearing procedures.
  • SECTION § 405.1032 - Issues before an ALJ or attorney adjudicator.
  • SECTION § 405.1034 - Requesting information from the QIC.
  • SECTION § 405.1036 - Description of an ALJ hearing process.
  • SECTION § 405.1037 - Discovery.
  • SECTION § 405.1038 - Deciding a case without a hearing before an ALJ.
  • SECTION § 405.1040 - Prehearing and posthearing conferences.
  • SECTION § 405.1042 - The administrative record.
  • SECTION § 405.1044 - Consolidated proceedings.
  • SECTION § 405.1046 - Notice of an ALJ or attorney adjudicator decision.
  • SECTION § 405.1048 - The effect of an ALJ's or attorney adjudicator's decision.
  • SECTION § 405.1050 - Removal of a hearing request from OMHA to the Council.
  • SECTION § 405.1052 - Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.
  • SECTION § 405.1054 - Effect of dismissal of a request for a hearing or request for review of QIC dismissal.
  • SECTION § 405.1056 - Remands of requests for hearing and requests for review.
  • SECTION § 405.1058 - Effect of a remand.

• Applicability of Medicare Coverage Policies

  • SECTION § 405.1060 - Applicability of national coverage determinations (NCDs).
  • SECTION § 405.1062 - Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.
  • SECTION § 405.1063 - Applicability of laws, regulations, CMS Rulings, and precedential decisions.

• Medicare Appeals Council Review

  • SECTION § 405.1134 - Extension of time to file action in Federal district court.
  • SECTION § 405.1136 - Judicial review.
  • SECTION § 405.1138 - Case remanded by a Federal district court.
  • SECTION § 405.1140 - Council review of ALJ decision in a case remanded by a Federal district court.
  • SECTION § 405.1100 - Medicare Appeals Council review: General.
  • SECTION § 405.1102 - Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.
  • SECTION § 405.1106 - Where a request for review or escalation may be filed.
  • SECTION § 405.1108 - Council actions when request for review or escalation is filed.
  • SECTION § 405.1110 - Council reviews on its own motion.
  • SECTION § 405.1112 - Content of request for review.
  • SECTION § 405.1114 - Dismissal of request for review.
  • SECTION § 405.1116 - Effect of dismissal of request for Council review or request for hearing.
  • SECTION § 405.1118 - Obtaining evidence from the Council.
  • SECTION § 405.1120 - Filing briefs with the Council.
  • SECTION § 405.1122 - What evidence may be submitted to the Council.
  • SECTION § 405.1124 - Oral argument.
  • SECTION § 405.1126 - Case remanded by the Council.
  • SECTION § 405.1128 - Action of the Council.
  • SECTION § 405.1130 - Effect of the Council's decision.
  • SECTION § 405.1132 - Request for escalation to Federal court.