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. § 405.926

Actions that are not initial determinations

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Actions that are not initial determinations and are not appealable under this subpart include, but are not limited to the following:

(a) Any determination for which CMS has sole responsibility, for example one of the following:

(1) If an entity meets the conditions for participation in the program.

(2) If an independent laboratory meets the conditions for coverage of services.

(3) Determination under the Medicare Secondary Payer provisions of section 1862(b) of the Act of the debtor for a particular recovery claim.

(b) The coinsurance amounts prescribed by regulation for outpatient services under the prospective payment system.

(c) Any issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a carrier has sole responsibility under Part B such as the establishment of a fee schedule set forth in part 414 of this chapter, or an inherent reasonableness adjustment pursuant to § 405.502(g), and any issue regarding the cost report settlement process under Part A.

(d) Whether an individual's appeal meets the qualifications for expedited access to judicial review provided in § 405.990.

(e) Any determination regarding whether a Medicare overpayment claim must be compromised, or collection action terminated or suspended under the Federal Claims Collection Act of 1966, as amended.

(f) Determinations regarding the transfer or discharge of residents of skilled nursing facilities in accordance with § 483.5 definition of `transfer and discharge' and § 483.15 of this chapter.

(g) Determinations regarding the readmission screening and annual resident review processes required by subparts C and E of part 483 of this chapter.

(h) Determinations for a waiver of Medicare Secondary Payer recovery under section 1862(b) of the Act.

(i) Determinations for a waiver of interest.

(j) Determinations for a finding regarding the general applicability of the Medicare Secondary Payer provisions (as opposed to the application of these provisions to a particular claim or claims for Medicare payment for benefits).

(k) Except as specified in § 405.924(b)(16), determinations under the Medicare Secondary Payer provisions of section 1862(b) of the Act that Medicare has a recovery against an entity that was or is required or responsible (directly, as an insurer or self-insurer; as a third party administrator; as an employer that sponsors, contributes to or facilitates a group health plan or a large group health plan; or otherwise) to make payment for services or items that were already reimbursed by the Medicare program.

(l) A contractor's, QIC's, ALJ's or attorney adjudicator's, or Council's determination or decision to reopen or not to reopen an initial determination, redetermination, reconsideration, decision, or review decision.

(m) Determinations that CMS or its contractors may participate in the proceedings on a request for an ALJ hearing or act as parties in an ALJ hearing or Council review.

(n) Determinations that a provider or supplier failed to submit a claim timely or failed to submit a timely claim despite being requested to do so by the beneficiary or the beneficiary's subrogee.

(o) Determinations with respect to whether an entity qualifies for an exception to the electronic claims submission requirement under part 424 of this chapter.

(p) Determinations by the Secretary of sustained or high levels of payment errors in accordance with section 1893(f)(3)(A) of the Act.

(q) A contractor's prior determination related to coverage of physicians' services.

(r) Requests for anticipated payment under the home health prospective payment system under § 409.43(c)(ii)(2) of this chapter.

(s) Claim submissions on forms or formats that are incomplete, invalid, or do not meet the requirements for a Medicare claim and returned or rejected to the provider or supplier.

(t) A contractor's prior authorization determination with regard to—

(1) Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)); and

(2) Hospital outpatient department (OPD) services.

(u) Issuance of notice to an individual entitled to Medicare benefits under Title XVIII of the Act when such individual received observation services as an outpatient for more than 24 hours, as specified under § 489.20(y) of this chapter.

[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37702, June 30, 2005; 80 FR 10618, Feb. 27, 2015; 80 FR 81706, Dec. 30, 2015; 81 FR 57267, Aug. 22, 2016; 81 FR 68847, Oct. 4, 2016; 82 FR 5107, Jan. 17, 2017; 84 FR 19869, May 7, 2019; 84 FR 61490, Nov. 12, 2019]
Notes of Decisions
Cited in 12 cases (2 in the last 5 years), 2009–2022 · leading case: Palomar Medical Center v. Kathleen Sebelius
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Palomar Medical Center v. Kathleen Sebelius (2012) ca9 · cites it 8× “Applying Thomas Jefferson, the magistrate judge concluded that the Secretary’s interpretation was consistent with both the plain language of 42 C.F.R. §§ 405.926 (Z) and 405.980(a)(5) and CMS’s statement in the interim final rule that it would enforce the good cause standard…”
St. Francis Hospital v. Sebelius (2014) nyed · cites it 8× “980 (a)(5) and 42 C.F.R. § 405.926 (Z), Plaintiffs claim would be placed beyond judicial review.”
Anghel v. Sebelius (2012) nyed · cites it 2× “” 42 C.F.R. § 405.926 . However, in comments made during the notice-and-comment rulemaking process, the Secretary stated that “Congress required contractors to identify a likelihood of sustained or high level of payment error.”
St. Francis Hospital v. Sebelius (2012) nyed · cites it 3× “) However, under 42 C.F.R. § 405.926 (Z), “[a] contractor’s .”
AMERICAN MEDICAL TECHNOLOGIES v. Johnson (2009) dcd · cites it 3× “¶¶ 46-48; 42 C.F.R. § 405.926 (s) (providing that a determination that a claim is “incomplete, invalid, or do[es] not meet the requirements for a Medicare claim” is not appealable).”
MORTON PLANT HOSPITAL ASSOCIATION, INC. v. Sebelius (2010) flmd · cites it 2× “980 (a)(5); see also 42 C.F.R. § 405.926 (i) (listing “contractor’s .”
Gentiva Healthcare Corporation v. Sebelius (2012) dcd “The Secretary promulgated regulations implementing this statutory provision, see 42 C.F.R. § 405.926 (p), and also addressed it in the Medicare Integrity Program Manual.”
Henry v. Azar (2021) dcd · cites it 5× “AR at 69 (citing 42 C.F.R. § 405.926 (c)). Mr. Henry subsequently requested that an administrative law judge (“ALJ”) within HHS review the QIC’s dismissal.”
First United Methodist Church v. Becerra (2022) ned · cites it 2× “980 ; see also 42 C.F.R. § 405.926 (l) (the “determination or decision to reopen or not to reopen an initial determination, redetermination, reconsideration decision, or review decision” is not appealable).”
American Medical Technologies, Inc. v. Leavitt (2009) dcd · cites it 3× “¶¶ 46-48; 42 C.F.R. § 405.926 (s) (providing that a determination that a claim is "incomplete, invalid, or do[es] not meet the requirements for a Medicare claim" is not appealable).”
PALOMAR MEDICAL CENTER v. Sebelius (2012) ca9 “ORDER The panel invites amicus briefs addressing the following questions: (1) Do the regulations at 42 C.F.R. §§ 405.926 (i) and 405.980(a)(5) bar administrative review of a contractor’s decision to reopen a Medicare claim, including the contractor’s compliance with the good…”
Raheem Nader v. Eric Hargan (2018) ca4 “17, 2015); 42 C.F.R. § 405.926 (l) (2014). Accordingly, we do not address Nader’s arguments on this issue.”
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.