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. § 405.906

Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews

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(a) Parties to the initial determination. The parties to the initial determination are the following individuals and entities:

(1) A beneficiary who files a claim for payment under Medicare Part A or Part B or has had a claim for payment filed on his or her behalf, or in the case of a deceased beneficiary, when there is no estate, any person obligated to make or entitled to receive payment in accordance with part 424, subpart E of this chapter. Payment by a third party payer does not entitle that entity to party status.

(2) A supplier who has accepted assignment for items or services furnished to a beneficiary that are at issue in the claim.

(3) A provider of services who files a claim for items or services furnished to a beneficiary.

(4) An applicable plan for an initial determination under § 405.924(b)(16) where Medicare is pursuing recovery directly from the applicable plan. The applicable plan is the sole party to an initial determination under § 405.924(b)(16) (that is, where Medicare is pursuing recovery directly from the applicable plan).

(b) Parties to the redetermination, reconsideration, proceedings on a request for hearing, and Council review. The parties to the redetermination, reconsideration, proceedings on a request for hearing, and Council review are—

(1) The parties to the initial determination in accordance with paragraph (a) of this section, except under paragraph (a)(1) of this section where a beneficiary has assigned appeal rights under § 405.912;

(2) A State agency in accordance with § 405.908;

(3) A provider or supplier that has accepted an assignment of appeal rights from the beneficiary according to § 405.912;

(4) A non-participating physician not billing on an assigned basis who, in accordance with section 1842(l) of the Act, may be liable to refund monies collected for services furnished to the beneficiary because those services were denied on the basis of section 1862(a)(1) of the Act; and

(5) A non-participating supplier not billing on an assigned basis who, in accordance with sections 1834(a)(18) and 1834(j)(4) of the Act, may be liable to refund monies collected for items furnished to the beneficiary.

(c) Appeals by providers and suppliers when there is no other party available. If a provider or supplier is not already a party to the proceeding in accordance with paragraphs (a) and (b) of this section, a provider of services or supplier may appeal an initial determination relating to services it rendered to a beneficiary who subsequently dies if there is no other party available to appeal the determination. This paragraph (c) does not apply to an initial determination with respect to an applicable plan under § 405.924(b)(16).

[70 FR 11472, Mar. 8, 2005, as amended at 80 FR 10617, Feb. 27, 2015; 82 FR 5106, Jan. 17, 2017]
Notes of Decisions
Cited in 8 cases (6 in the last 5 years), 2013–2026 · leading case: Global Rescue Jets, LLC v. Kaiser Foundation Health Plan
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Global Rescue Jets, LLC v. Kaiser Foundation Health Plan (2022) ca9 “pan> (1984), the Supreme Court held that federal courts generally lack subject matter jurisdiction to review the denial of a claim for Medicare benefits unless the beneficiary exhausts all available levels 1 Providers are also subject to this review process when asserting claims…”
United States Ex Rel. Zizic v. Q2Administrators, LLC (2013) ca3 “Nonetheless, the list of possible parties who may participate in the proceedings includes: beneficiaries, provider-assignees, supplier-assignees, and state agencies, 42 C.F.R. § 405.906 ; HHS and its contractors, § 405.”
Row 1 Inc. v. Xavier Becerra (2024) cadc “…claims before the agency include program beneficiaries and their providers. See 42 C.F.R. §§ 405.906 (a), 405.912(a). Providers can either assert claims on their own behalf or as assignees of the beneficiaries. See id. B. Factual and Procedural H”
Odell v. Azar (2018) nvd “…index="5" url="https://cite.case.law/citations/?q=42%20C.F.R.%20%C2%A7%20405.906"> 42 C.F.R. § 405.906 (a)(2). A claimant first submits a claim to their MAC for an initial determination. 42 U.S.C. § 1395ff(a) ; <sp”
Henry v. Azar (2021) dcd “Henry’s reimbursement claim, see 42 C.F.R. § 405.906 ; 42 U.”
Dynasty Healthcare, LLC v. Nat'l Gov't Services, Inc. (2023) ca2 “4 § 1395ff(b)(1)(A); see also 42 C.F.R. §§ 405.906 (a), 405.”
General Medicine, P.C. v. Department of Health and Human Services, Secretary of (2022) mied “) She concluded that “the 73 beneficiaries in this case are parties as defined by 42 C.F.R. § 405.906 and as such, the beneficiaries are entitled to receive a copy of the request for hearing submitted by the [General Medicine].”
Skincure Oncology, LLC v. Kennedy Jr. (2026) dcd “Reply at 7; Opp’n at 20; 42 C.F.R. §§ 405.906 (a), 405.”
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