All sources category
Reimbursement Payment
Payment, reimbursement, rate, claim, and payment-method provisions.
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Source collection
All sources
Category group
Payment Program Integrity
Category
Reimbursement Payment
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Expand an instrument to inspect matching provisions
Instruments
2
Shown
50
Citation
42 CFR § 405.1006
Amount in controversy required for an ALJ hearing and judicial review.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Amount in controversy, Medicare appeals
Citation
42 CFR § 405.1014
Request for an ALJ hearing or a review of a QIC dismissal.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Alj hearing request, Qic dismissal review
Citation
42 CFR § 405.1106
Where a request for review or escalation may be filed.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare appeals filing, Reimbursement review escalation
Citation
42 CFR § 405.1204
Expedited reconsiderations.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Expedited reconsideration, Medicare payment appeals
Citation
42 CFR § 405.1210
Notifying eligible beneficiaries of appeal rights when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
Group
Patient Rights Safety
Category
Patient Rights
Domain
Patient Rights
Topics
Beneficiary appeal rights, Inpatient to outpatient reclassification
Citation
42 CFR § 405.1212
Expedited reconsideration procedures regarding Part A coverage when a beneficiary is reclassified from an inpatient to an outpatient receiving observation services.
Group
Patient Rights Safety
Category
Grievance Complaints
Domain
Patient Rights
Topics
Expedited reconsideration, Part a coverage
Citation
42 CFR § 405.1803
Contractor determination and notice of amount of program reimbursement.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Reimbursement determination, Notice of program reimbursement
Citation
42 CFR § 405.1804
Matters not subject to administrative and judicial review under prospective payment.
Neither administrative nor judicial review is available for controversies about the following matters:
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Prospective payment review, Administrative review limitations
Citation
42 CFR § 405.1805
Parties to contractor determination.
The parties to the contractor's determination are the provider and any other entity found by the contractor to be a related organization of the provider under § 413.17 of this chapter.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare contractor determination, Provider related organization
Citation
42 CFR § 405.1809
Contractor hearing procedures.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare contractor hearing procedures, Reimbursement appeals process
Citation
42 CFR § 405.1811
Right to contractor hearing; contents of, and adding issues to, hearing request.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare hearing request requirements, Reimbursement appeal issues
Citation
42 CFR § 405.1813
Good cause extension of time limit for requesting a contractor hearing.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare hearing request deadline, Good cause extension
Citation
42 CFR § 405.1814
Contractor hearing officer jurisdiction.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare contractor hearing, Administrative hearing jurisdiction
Citation
42 CFR § 405.1815
Parties to proceedings before the contractor hearing officer(s).
When a provider files a request for a contractor hearing in accordance with § 405.1811 of this subpart, the parties to all proceedings before the contractor hearing officer(s) are the provider and, if applicable, any other entity found b...
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare provider appeals, Contractor hearing procedures
Citation
42 CFR § 405.1819
Conduct of contractor hearing.
The hearing shall be open to all parties thereto (see § 405.1815) and to representatives of the contractor and of the Centers for Medicare & Medicaid Services (see § 405.1815).
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare contractor hearing, Administrative hearing procedures
Citation
42 CFR § 405.1821
Prehearing discovery and other proceedings prior to the contractor hearing.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare contractor hearing, Prehearing discovery
Citation
42 CFR § 405.1823
Evidence at contractor hearing.
Evidence may be received at the contractor hearing even though inadmissible under the rules of evidence applicable to court procedure.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Evidence admissibility, Medicare contractor hearing
Citation
42 CFR § 405.1827
Record of proceedings before the contractor hearing officer(s).
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Record of proceedings, Medicare contractor hearing
Citation
42 CFR § 405.1833
Effect of contractor hearing decision.
A contractor hearing decision issued in accordance with § 405.1831 of this subpart is final and binding on all parties to the contractor hearing and on the contractor, unless the hearing decision is reviewed by a CMS reviewing official i...
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Contractor hearing decision, Reimbursement appeal finality
Citation
42 CFR § 405.1834
CMS reviewing official procedure.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Cms reviewing official, Administrative appeals
Citation
42 CFR § 405.1835
Right to Board hearing; contents of, and adding issues to, hearing request.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Board hearing rights, Medicare hearing request
Citation
42 CFR § 405.1836
Good cause extension of time limit for requesting a Board hearing.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Hearing request extension, Good cause extension
Citation
42 CFR § 405.1837
Group appeals.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare appeals, Group appeals
Citation
42 CFR § 405.1839
Amount in controversy.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Amount in controversy, Medicare appeals
Citation
42 CFR § 405.1840
Board jurisdiction.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Provider reimbursement, Medicare appeals board
Citation
42 CFR § 405.1842
Expedited judicial review.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare appeals, Judicial review
Citation
42 CFR § 405.1843
Parties to proceedings in a Board appeal.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare appeals, Board appeal parties
Citation
42 CFR § 405.1845
Composition of Board; hearings, decisions, and remands.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare appeals, Provider reimbursement review board
Citation
42 CFR § 405.1853
Board proceedings prior to any hearing; discovery.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare reimbursement appeals, Board discovery procedures
Citation
42 CFR § 405.1855
Evidence at Board hearing.
Evidence may be received at the Board hearing even though inadmissible under the rules of evidence applicable to court procedure.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare reimbursement appeals, Board hearing evidence
Citation
42 CFR § 405.1867
Scope of Board's legal authority.
In exercising its authority to conduct proceedings under this subpart, the Board must comply with all the provisions of Title XVIII of the Act and regulations issued thereunder, as well as CMS Rulings issued under the authority of the Ad...
Group
Internal Review
Category
Outside Hospital Scope
Domain
Billing Reimbursement
Topics
Board legal authority, Cms rulings
Citation
42 CFR § 405.1871
Board hearing decision.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare appeals, Board hearing decision
Citation
42 CFR § 405.1873
Board review of compliance with the reimbursement requirement of an appropriate cost report claim.
Group
Payment Program Integrity
Category
Cost Reporting
Domain
Billing Reimbursement
Topics
Cost report claim, Reimbursement compliance
Citation
42 CFR § 405.1875
Administrator review.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Cms administrator review, Medicare appeals process
Citation
42 CFR § 405.1877
Judicial review.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Judicial review, Medicare appeals process
Citation
42 CFR § 405.1885
Reopening a contractor determination or reviewing entity decision.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Reopening determinations, Medicare appeals
Citation
42 CFR § 405.1887
Notice of reopening; effect of reopening.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Notice of reopening, Medicare appeals
Citation
42 CFR § 405.1889
Effect of a revision; issue-specific nature of appeals of revised determinations and decisions.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Payment appeals, Reimbursement determinations
Citation
42 CFR § 405.211
Coverage of items and services in FDA-approved IDE studies.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Ide studies, Investigational device exemption
Citation
42 CFR § 405.212
Medicare Coverage IDE study criteria.
Group
Research Human Subjects
Category
Human Subjects Protections
Domain
Billing Reimbursement
Topics
Medicare coverage, Investigational device exemption
Citation
42 CFR § 405.2411
Scope of benefits.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare benefits scope, Reimbursement coverage
Citation
42 CFR § 405.2464
Payment rate.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Payment rates, Medicare reimbursement
Citation
42 CFR § 405.2468
Allowable costs.
Group
Payment Program Integrity
Category
Cost Reporting
Domain
Billing Reimbursement
Topics
Medicare allowable costs, Rural health clinic cost reporting
Citation
42 CFR § 405.350
Individual's liability for payments made to providers and other persons for items and services furnished the individual.
Any payment made under title XVIII of the Act to any provider of services or other person with respect to any item or service furnished an individual shall be regarded as a payment to the individual, and adjustment shall be made pursuant...
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare payment liability, Payment adjustment
Citation
42 CFR § 405.371
Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Medicare payment suspension, Payment offset
Citation
42 CFR § 405.372
Proceeding for suspension of payment.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Payment suspension proceedings, Due process for payment suspension
Citation
42 CFR § 405.375
Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Administrative determination, Rebuttal statement
Citation
42 CFR § 405.379
Limitation on recoupment of provider and supplier overpayments.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Overpayment recoupment, Provider payment recovery
Citation
42 CFR § 405.502
Criteria for determining reasonable charges.
Group
Payment Program Integrity
Category
Reimbursement Payment
Domain
Billing Reimbursement
Topics
Reasonable charge criteria, Medicare payment methodology