C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER A—GENERAL PROVISIONS › PART 400—INTRODUCTION; DEFINITIONS › Subpart B—Definitions

42 C.F.R. § 400.202

Definitions specific to Medicare

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As used in connection with the Medicare program, unless the context indicates otherwise—

Carrier means an entity that has a contract with CMS to determine and make Medicare payments for Part B benefits payable on a charge basis and to perform other related functions.

Critical access hospital (CAH) means a facility designated by HFCA as meeting the applicable requirements of section 1820 of the Act and of subpart F of part 485 of this chapter.

Departmental Appeals Board means: (1) Except as provided in paragraphs (2) and (3) of this definition, a Board established in the office of the Secretary, whose members act in panels to provide impartial review of disputed decisions made by operating components of the Department or by ALJs.

(2) For purposes of review of ALJ decisions under part 405, subparts G and H; part 417, subpart Q; part 422, subpart M; and part 478, subpart B of this chapter, the Medicare Appeals Council designated by the Board Chair.

(3) For purposes of part 426 of this chapter, a Member of the Board and, at the discretion of the Board Chair, any other Board staff appointed by the Board Chair to perform a review under that part.

Entitled means that an individual meets all the requirements for Medicare benefits.

Essential access community hospital (EACH) means a hospital designated by CMS as meeting the applicable requirements of section 1820 of the Act and of subpart G of part 412 of this chapter, as in effect on September 30, 1997.

GME stands for graduate medical education.

Hospital insurance benefits means payments on behalf of, and in rare circumstances directly to, an entitled individual for services that are covered under Part A of title XVIII of the Act.

Intermediary means an entity that has a contract with CMS to determine and make Medicare payments for Part A or Part B benefits payable on a cost basis and to perform other related functions.

Local coverage determination (LCD) means a decision by a fiscal intermediary or a carrier under Medicare Part A or Part B, as applicable, whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with section 1862(a)(1)(A) of the Act. An LCD may provide that a service is not reasonable and necessary for certain diagnoses and/or for certain diagnosis codes. An LCD does not include a determination of which procedure code, if any, is assigned to a service or a determination with respect to the amount of payment to be made for the service.

Medicare integrity program contractor means an entity that has a contract with CMS under section 1893 of the Act to perform exclusively one or more of the program integrity activities specified in that section.

Medicare Part A means the hospital insurance program authorized under Part A of title XVIII of the Act.

Medicare Part B means the supplementary medical insurance program authorized under Part B of title XVIII of the Act.

Medicare Part C means the choice of Medicare benefits through Medicare Advantage plans authorized under Part C of the title XVIII of the Act.

Medicare Part D means the voluntary prescription drug benefit program authorized under Part D of title XVIII of the Act.

National coverage determination (NCD) means a decision that CMS makes regarding whether to cover a particular service nationally under title XVIII of the Act. An NCD does not include a determination of what code, if any, is assigned to a service or a determination with respect to the amount of payment to be made for the service.

Nonparticipating supplier means a supplier that does not have an agreement with CMS to participate in Part B of Medicare in effect on the date of the service.

Participating supplier means a supplier that has an agreement with CMS to participate in Part B of Medicare in effect on the date of the service.

Payment on an assignment-related basis means payment for Part B services—

(1) To a physician or other supplier that accepts assignment from the beneficiary, in accordance with § 424.55 or § 424.56 of this chapter;

(2) To a physician or other supplier after the beneficiary's death, in accordance with § 424.64(c)(1) of this chapter; or

(3) To an entity that pays the physician or other supplier under a health benefit plan, in accordance with § 424.66 of this chapter.

Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services.

Railroad retirement benefits means monthly benefits payable to individuals under the Railroad Retirement Act of 1974 (45 U.S.C. beginning at section 231).

Services means medical care or services and items, such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital, CAH, or SNF facilities.

Supplementary medical insurance benefits means payment to or on behalf of an entitled individual for services covered under Part B of title XVIII of the Act.

Supplier means a physician or other practitioner, or an entity other than a provider, that furnishes health care services under Medicare.

[48 FR 12534, Mar. 25, 1983] Editorial Note:For Federal Register citations affecting § 400.202, see the List of CFR Sections Affected, which appears in the Finding Aids section of the printed volume and at www.govinfo.gov.
Notes of Decisions
Cited in 50 cases (13 in the last 5 years), 1985–2025 · leading case: United States Ex Rel. Williams v. Renal Care Group, Inc.
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United States Ex Rel. Williams v. Renal Care Group, Inc. (2012) ca6 · cites it 6× “§ 1395rr(b)(1); see also 42 C.F.R. § 400.202 (defining a supplier as “a physician or other practitioner, or an entity other than a provider, that furnishes health care services under Medicare”).”
Fischer v. United States (2000) scotus · cites it 2× “§§ 1395c, 1395j; 42 CFR § 400.202 (1999) (defining "beneficiary" as the "person who is entitled to Medicare benefits"); Shalala v.”
Arturo Porzecanski v. Alex Azar (2019) cadc “…“that a service is not reasonable and necessary for certain diagnoses.” 42 C.F.R. § 400.202 . If the contractor denies the beneficiary’s claim, the beneficiary is entitled to appeal his claim to HHS. See 42 U.S.C. § 1395ff(b)(1)(A). Initially, he must obtain a…”
Power Mobility Coalition v. Leavitt (2005) dcd “§ 1395x(d); 42 C.F.R. § 400.202 .). Part B of the Medicare Act provides supplementary medical insurance for covered medical services, such as doctors’ visits, diagnostic testing, and covered medical supplies, such as DME.”
Charlotte-Mecklenburg Hospital Authority v. North Carolina Department of Health & Human Services (2009) ncctapp · cites it 3× “42 C.F.R. § 400.202 (2005). The requirement applies whether payment is sought in the first instance pursuant to Medicare or whether payment is sought pursuant to Medicare for claims that previously were paid by Medicaid.”
City of Gadsden v. Boman (2013) ala · cites it 2× “” 42 C.F.R. § 400.202 . The Board members argue: “For purposes relevant to this case, there are two primary Medicare coverages — Part A (hospital insurance) and Part B (medical insurance).”
Jewish Hospital, Inc. v. Secretary of Health and Human Services (1994) ca6 “§ 1395d (Medicare benefits to person consist of “entitlement to have pay *279 ments made on his behalf’) and 42 C.F.R. § 400.202 (“Definitions specific to Medicare[:] .”
United States v. Garrison (1998) ca11 “§ 1395d; 42 C.F.R. § 400.202 (1995). 4 .”
Catholic Health Initiatives Iowa Corp. v. Sebelius (2013) cadc “See also 42 C.F.R. § 400.202 (“Entitled means that an individual meets all the requirements for Medicare benefits”).”
Community Care, LLC v. Leavitt (2008) ca5 · cites it 2× “§ 1395x(u); 42 C.F.R. § 400.202 ; 8 (2) CCH’s SNF was certified by CMS as a Medicare provider on April 1, 1999, five years after the hospital was certified as a Medicare provider; (3) the SNF was issued its own unique provider number different from that of the hospital; (4) to…”
Willowood of Great Barrington, Inc. v. Sebelius (2009) mad · cites it 2× “See also 42 C.F.R. §§ 400.202 , 405.1060. Such NCDs “generally outline the condi *106 tions for which a service is considered to be covered (or not covered)” and “are usually issued as a program instruction.”
Hays v. Leavitt (2008) dcd · cites it 2× “…or a determination with respect to the amount of payment to be made for the service.” 42 C.F.R. § 400.202 . B. The Least Costly Alternative Policy and the Local Coverage Determination for DuoNeb The least costly alternative policy at issue in this case is found in the…”
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