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. § 405.920

Initial determinations

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After a claim is filed with the appropriate contractor in the manner and form described in subpart C of part 424 of this chapter, the contractor must—

(a) Determine if the items and services furnished are covered or otherwise reimbursable under title XVIII of the Act;

(b) Determine any amounts payable and make payment accordingly; and

(c) Notify the parties to the initial determination of the determination in accordance with § 405.921.

Notes of Decisions
Cited in 27 cases (14 in the last 5 years), 2010–2026 · leading case: Arturo Porzecanski v. Alex Azar
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Arturo Porzecanski v. Alex Azar (2019) cadc · cites it 2× “” 42 C.F.R. § 405.920 . Initial coverage determinations are made by contractors HHS hires to manage the preliminary claims administration process in designated geographic areas.”
Maxmed Healthcare, Inc. v. Thomas Price (2017) ca5 “See 42 C.F.R. § 405.920 . A provider who is displeased with the Medicare Administrative Contractor’s initial determination may then seek a “redetermination”—the first step in a five-step appeal process.”
Global Rescue Jets, LLC v. Kaiser Foundation Health Plan (2022) ca9 “Before filing suit in court, a Medicare beneficiary must proceed through five levels of administrative review, described in regulations issued by CMS as follows: (1) an initial determination by the medicare administrative contractor, 42 C.F.R. § 405.920 ; (2) a redetermination…”
Anniken Prosser v. Xavier Becerra (2021) ca7 “See 42 C.F.R. § 405.920 (a). Contractors may issue a local coverage determination that categorically de- cides whether a treatment is covered, a determination that be- comes binding on the issuing contractor for future claims.”
International Rehabilitative Sciences Inc. v. Sebelius (2012) ca9 “If the supplier is dissatisfied with the redetermination, it may have a qualified independent contractor reconsider the claim.”
Edwin R. Banks v. Secretary, Department of Health and Human Services (2022) ca11 “§ 1395ff(a); 42 C.F.R. § 405.920 . Second, if the beneficiary is dissatisfied with the initial determination, he may request a “re- determination” by the contractor.”
Palomar Medical Center v. Kathleen Sebelius (2012) ca9 “§ 1395ff(a); 42 C.F.R. § 405.920 . Initial determinations are appealable.”
Art of Healing Medicine, P.C. v. Burwell (2015) nyed · cites it 2× “§ 1395ff(a)(l); 42 C.F.R. §§ 405.920 , 405.921. This “initial determination” notice indicates whether there is coverage and, if so, the amount payable.”
Porzecanski v. Azar (2018) cadc “42 C.F.R. §§ 405.920 , 405.924(b). The initial contractor may review the claim individually, or the contractor may deny the claim automatically by relying on a "local coverage determination," which is a decision promulgated by the contractor "to provide guidance to the public…”
Gentiva Healthcare Corporation v. Sebelius (2012) dcd “Consistent with Medicare regulations governing the appeals process, see 42 C.F.R. §§ 405.920 , 405.924(b), 405.940-58, Gentiva first sought a redetermination from Cahaba and then sought reconsideration by another Medicare contractor.”
MORTON PLANT HOSPITAL ASSOCIATION, INC. v. Sebelius (2010) flmd “§ 1395ff(a); 42 C.F.R. §§ 405.920 , 405.924. If a provider is not satisfied with the Intermediary’s initial determination, that provider may request a “redetermination” from the Intermediary.”
International Rehabilitative Sciences, Inc. v. Sebelius (2010) wawd “§ 1395ff(a)-(c); 42 C.F.R. §§ 405.920 , .940, .960, .1002.”
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