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. § 405.928

Effect of the initial determination

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(a) An initial determination described in § 405.924(a) is binding unless it is revised or reconsidered in accordance with 20 CFR 404.907, or revised as a result of a reopening in accordance with 20 CFR 404.988.

(b) An initial determination described in § 405.924(b) is binding upon all parties to the initial determination unless—

(1) A redetermination is completed in accordance with § 405.940 through § 405.958; or

(2) The initial determination is revised as a result of a reopening in accordance with § 405.980.

(c) An initial determination listed in § 405.924(b) where a party submits a timely, valid request for redetermination under § 405.942 through § 405.944 must be processed as a redetermination under § 405.948 through § 405.958 unless the initial determination involves a clerical error or other minor error or omission.

Notes of Decisions
Cited in 4 cases (2 in the last 5 years), 2014–2022 · leading case: Am. Hosp. Ass'n v. Sebelius, 68 F. Supp. 3d 54 (D.D.C. 2014).
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Am. Hosp. Ass'n v. Sebelius, 68 F. Supp. 3d 54 (D.D.C. 2014). “See 42 C.F.R. § 405.928 (“[a]n initial determination .”
First United Methodist Church v. Becerra (D. Neb. 2022). · cites it 2× “” 42 C.F.R. § 405.928 (b). The Secretary has promulgated regulations applicable to “redeterminations,” “reconsiderations,” and “reopenings.”
Thumann v. Sec'y, Dep't of Health & Human Servs. (S.D. Ohio 2021). “See 42 C.F.R. § 405.928 . If, however, the MAC determines that coverage is not appropriate, the beneficiary may seek review of the MAC’s decision.”
Acute Care Ambulance Serv., LLC v. Alex M. Azar II (S.D. Tex. 2020). “163 But Plaintiff’s authority for this proposition is merely a law review article, and however well-reasoned the article or luminary its author, this Court is bound by Fifth Circuit precedent holding that the type of hearing necessary or process due “is a function of the context…”
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