C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

42 C.F.R. § 405.904

Medicare initial determinations, redeterminations and appeals: General description

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(a) General overview—(1) Entitlement appeals. The SSA makes an initial determination on an application for Medicare benefits and/or entitlement of an individual to receive Medicare benefits. A beneficiary who is dissatisfied with the initial determination may request, and SSA will perform, a reconsideration in accordance with 20 CFR part 404, subpart J if the requirements for obtaining a reconsideration are met. Following the reconsideration, the beneficiary may request a hearing before an ALJ under this subpart (42 CFR part 405, subpart I). If the beneficiary obtains a hearing before an ALJ and is dissatisfied with the decision of the ALJ, or if the beneficiary requests a hearing and no hearing is conducted, and the beneficiary is dissatisfied with the decision of an ALJ or an attorney adjudicator, he or she may request the Council to review the case. Following the action of the Council, the beneficiary may be entitled to file suit in Federal district court.

(2) Claim appeals. The Medicare contractor makes an initial determination when a claim for Medicare benefits under Part A or Part B is submitted. A beneficiary who is dissatisfied with the initial determination may request that the contractor perform a redetermination of the claim if the requirements for obtaining a redetermination are met. Following the contractor's redetermination, the beneficiary may request, and the Qualified Independent Contractor (QIC) will perform, a reconsideration of the claim if the requirements for obtaining a reconsideration are met. Following the reconsideration, the beneficiary may request a hearing before an ALJ. If the beneficiary obtains a hearing before the ALJ and is dissatisfied with the decision of the ALJ, or if the beneficiary requests a hearing and no hearing is conducted, and the beneficiary is dissatisfied with the decision of an ALJ or attorney adjudicator, he or she may request the Council to review the case. If the Council reviews the case and issues a decision, and the beneficiary is dissatisfied with the decision, the beneficiary may file suit in Federal district court if the amount remaining in controversy and the other requirements for judicial review are met.

(b) Non-beneficiary appellants. In general, the procedures described in paragraph (a) of this section are also available to parties other than beneficiaries either directly or through a representative acting on a party's behalf, consistent with the requirements of this subpart I. A provider generally has the right to judicial review only as provided under section 1879(d) of the Act; that is, when a determination involves a finding that services are not covered because—

(1) They were custodial care (see § 411.15(g) of this chapter); they were not reasonable and necessary (see § 411.15(k) of this chapter); they did not qualify as covered home health services because the beneficiary was not confined to the home or did not need skilled nursing care on an intermittent basis (see § 409.42(a) and (c)(1) of this chapter); or they were hospice services provided to a non-terminally ill individual (see § 418.22 of this chapter); and

(2) Either the provider or the beneficiary, or both, knew or could reasonably be expected to know that those services were not covered under Medicare.

[70 FR 11472, Mar. 8, 2005, as amended at 82 FR 5106, Jan. 17, 2017]
Notes of Decisions
Cited in 66 cases (28 in the last 5 years), 2009–2026 · leading case: Ctr. for Dermatology & Ski v. Sylvia Mathews Burwell, 770 F.3d 586 (7th Cir. 2014).
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Ctr. for Dermatology & Ski v. Sylvia Mathews Burwell, 770 F.3d 586 (7th Cir. 2014). · cites it 4× “Second, if the claimant is dissatisfied with the redetermination decision, he may request a reconsideration of the claim by a QIC.”
Am. Hosp. Ass'n v. Thomas Price, 867 F.3d 160 (D.C. Cir. 2017). · cites it 8× “§§ 1395ff(a)(1)- (2), 1395kk-1(a); 42 C.F.R. §§ 405.904 (a)(2), 405.920- 405.”
Fam. Rehab., Inc. v. Azar, 886 F.3d 496 (5th Cir. 2018). · cites it 2× “§ 1395kk-1 ; 42 C.F.R. §§ 405.904 (a)(2), 405.920 - 405.”
Am. Hosp. Ass'n v. Sylvia Burwell, 812 F.3d 183 (D.C. Cir. 2016). “§§ 1395ff(a)(l)-(2), 1395kk-l(a); 42 C.F.R. §§ 405.904 (a)(2), 405.920-405.”
Med-Cert Home Care, LLC v. Azar, 365 F. Supp. 3d 742 (N.D. Tex. 2019). · cites it 3× “Med-Cert appealed the ZPIC's overpayment determination to the first level of the Medicare administrative appeals process, 42 C.F.R. § 405.904 (a)(2), requesting a redetermination from the Medicare Administrative Contractor ("MAC") on April 26, 2017.”
Randall D. Wolcott, Md, Pa v. Sebelius, 635 F.3d 757 (5th Cir. 2011). “42 C.F.R. § 405.904 (a)(2). C. Factual and Procedural Background Because this appeal concerns motions to dismiss under Federal Rule of Civil Procedure 12(b), the facts presented below are as alleged by Wolcott.”
Illinois Ins. Guar. F v. Xavier Becerra, 33 F.4th 916 (7th Cir. 2022). · cites it 2× “§ 1395ff(a)(1); 42 C.F.R. §§ 405.904 (a)(2), 405.924(b)(16).”
Am. Hosp. Ass'n v. Azar, 895 F.3d 822 (D.C. Cir. 2018). “§ 1395ff ; 42 C.F.R. § 405.904 . Congress has precluded judicial review of various classifications, calculations, and adjustments of the OPPS reimbursement rates.”
Global Rescue Jets, LLC v. Kaiser Found. Health Plan, 30 F.4th 905 (9th Cir. 2022). “§ 1395kk-1(a); 42 C.F.R. § 405.904 (a)(2). To resolve disputes over a Medicare beneficiary’s entitlement to benefits, Congress established a detailed administrative review scheme that borrowed elements of the review scheme governing claims for Social Security benefits.”
Popkin v. Burwell, 172 F. Supp. 3d 161 (D.D.C. 2016). · cites it 2× “§§ 1395kk-l(a), 1395ff(a)(l)-(2); 42 C.F.R. § 405.904 (a)(2). When a Medicai’e Administrative Contractor denies or limits payment on a Claim on initial determination, there is a four-level appeal process.”
Am. Hosp. Ass'n v. Azar, 385 F. Supp. 3d 1 (D.C. Cir. 2019). “§ 1395ff ; 42 C.F.R. § 405.904 ); see also Pls.' Mem.”
S. Rehab. Grp., P.L.L.C. v. Sec'y of Health & Human Servs., 732 F.3d 670 (6th Cir. 2013). “See 42 C.F.R. § 405.904 (a)(2) (reciting system of claim appeals); 42 U.”
Show all 66 citing cases →
— 42 C.F.R. § 405.904(a) — 1 case
Honey v. Bayhealth Med. Ctr., Inc. (Del. Super. Ct. 2015).
— 42 C.F.R. § 405.904(a)(1) — 1 case
(SS)Courtney v. Soc. Sec. Off. (E.D. Cal. 2021).
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