Code of Federal Regulations > Title 42 > Chapter IV > Part 405 > Subpart I - Subpart I—Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B)

U.S. Code of Federal Regulations

Regulations most recently checked for updates: Aug 27, 2025

INITIAL DETERMINATIONS

§ 405.920 - Initial determinations.

§ 405.921 - Notice of initial determination.

§ 405.922 - Time frame for processing initial determinations.

§ 405.924 - Actions that are initial determinations.

§ 405.925 - Decisions of utilization review committees.

§ 405.926 - Actions that are not initial determinations.

§ 405.927 - Initial determinations subject to the reopenings process.

§ 405.928 - Effect of the initial determination.

§ 405.929 - Post-payment review.

§ 405.930 - Failure to respond to additional documentation request.

§ 405.900 - Basis and scope.

§ 405.902 - Definitions.

§ 405.903 - Prepayment review.

§ 405.904 - Medicare initial determinations, redeterminations and appeals: General description.

§ 405.906 - Parties to the initial determinations, redeterminations, reconsiderations, hearings, and reviews.

§ 405.908 - Medicaid State agencies.

§ 405.910 - Appointed representatives.

§ 405.912 - Assignment of appeal rights.

RETROSPECTIVE APPEALS FOR CHANGES IN PATIENT STATUS THAT RESULTED IN DENIAL OF PART A COVERAGE FOR HOSPITAL SERVICES

§ 405.931 - Scope, basis, and definitions.

§ 405.932 - Right to appeal a denial of Part A coverage resulting from a change in patient status.

§ 405.934 - Reconsideration.

§ 405.936 - Hearings before an ALJ and decisions by an ALJ or Attorney Adjudicator.

§ 405.938 - Review by the Medicare Appeals Council and judicial review.

REDETERMINATIONS

§ 405.940 - Right to a redetermination.

§ 405.942 - Time frame for filing a request for a redetermination.

§ 405.944 - Place and method of filing a request for a redetermination.

§ 405.946 - Evidence to be submitted with the redetermination request.

§ 405.947 - Notice to the beneficiary of applicable plan's request for a redetermination.

§ 405.948 - Conduct of a redetermination.

§ 405.950 - Time frame for making a redetermination.

§ 405.952 - Withdrawal or dismissal of a request for a redetermination.

§ 405.954 - Redetermination.

§ 405.956 - Notice of a redetermination.

§ 405.958 - Effect of a redetermination.

RECONSIDERATION

§ 405.960 - Right to a reconsideration.

§ 405.962 - Timeframe for filing a request for a reconsideration.

§ 405.964 - Place and method of filing a request for a reconsideration.

§ 405.966 - Evidence to be submitted with the reconsideration request.

§ 405.968 - Conduct of a reconsideration.

§ 405.970 - Timeframe for making a reconsideration following a contractor redetermination.

§ 405.972 - Withdrawal or dismissal of a request for reconsideration or review of a contractor's dismissal of a request for redetermination.

§ 405.974 - Reconsideration and review of a contractor's dismissal of a request for redetermination.

§ 405.976 - Notice of a reconsideration.

§ 405.978 - Effect of a reconsideration.

REOPENINGS

§ 405.980 - Reopening of initial determinations, redeterminations, reconsiderations, decisions, and reviews.

§ 405.982 - Notice of a revised determination or decision.

§ 405.984 - Effect of a revised determination or decision.

§ 405.986 - Good cause for reopening.

EXPEDITED ACCESS TO JUDICIAL REVIEW

§ 405.990 - Expedited access to judicial review.

ALJ HEARINGS

§ 405.1000 - Hearing before an ALJ and decision by an ALJ or attorney adjudicator: General rule.

§ 405.1002 - Right to an ALJ hearing.

§ 405.1004 - Right to a review of QIC notice of dismissal.

§ 405.1006 - Amount in controversy required for an ALJ hearing and judicial review.

§ 405.1008 - Parties to the proceedings on a request for an ALJ hearing.

§ 405.1010 - When CMS or its contractors may participate in the proceedings on a request for an ALJ hearing.

§ 405.1012 -

§ 405.1014 - Request for an ALJ hearing or a review of a QIC dismissal.

§ 405.1016 - Time frames for deciding an appeal of a QIC reconsideration or escalated request for a QIC reconsideration.

§ 405.1018 - Submitting evidence.

§ 405.1020 - Time and place for a hearing before an ALJ.

§ 405.1022 - Notice of a hearing before an ALJ.

§ 405.1024 - Objections to the issues.

§ 405.1026 - Disqualification of the ALJ or attorney adjudicator.

§ 405.1028 - Review of evidence submitted by parties.

§ 405.1030 - ALJ hearing procedures.

§ 405.1032 - Issues before an ALJ or attorney adjudicator.

§ 405.1034 - Requesting information from the QIC.

§ 405.1036 - Description of an ALJ hearing process.

§ 405.1037 - Discovery.

§ 405.1038 - Deciding a case without a hearing before an ALJ.

§ 405.1040 - Prehearing and posthearing conferences.

§ 405.1042 - The administrative record.

§ 405.1044 - Consolidated proceedings.

§ 405.1046 - Notice of an ALJ or attorney adjudicator decision.

§ 405.1048 - The effect of an ALJ's or attorney adjudicator's decision.

§ 405.1050 - Removal of a hearing request from OMHA to the Council.

§ 405.1052 - Dismissal of a request for a hearing before an ALJ or request for review of a QIC dismissal.

§ 405.1054 - Effect of dismissal of a request for a hearing or request for review of QIC dismissal.

§ 405.1056 - Remands of requests for hearing and requests for review.

§ 405.1058 - Effect of a remand.

APPLICABILITY OF MEDICARE COVERAGE POLICIES

§ 405.1060 - Applicability of national coverage determinations (NCDs).

§ 405.1062 - Applicability of local coverage determinations and other policies not binding on the ALJ or attorney adjudicator and Council.

§ 405.1063 - Applicability of laws, regulations, CMS Rulings, and precedential decisions.

MEDICARE APPEALS COUNCIL REVIEW

§ 405.1134 - Extension of time to file action in Federal district court.

§ 405.1136 - Judicial review.

§ 405.1138 - Case remanded by a Federal district court.

§ 405.1140 - Council review of ALJ decision in a case remanded by a Federal district court.

§ 405.1100 - Medicare Appeals Council review: General.

§ 405.1102 - Request for Council review when ALJ or attorney adjudicator issues decision or dismissal.

§ 405.1106 - Where a request for review or escalation may be filed.

§ 405.1108 - Council actions when request for review or escalation is filed.

§ 405.1110 - Council reviews on its own motion.

§ 405.1112 - Content of request for review.

§ 405.1114 - Dismissal of request for review.

§ 405.1116 - Effect of dismissal of request for Council review or request for hearing.

§ 405.1118 - Obtaining evidence from the Council.

§ 405.1120 - Filing briefs with the Council.

§ 405.1122 - What evidence may be submitted to the Council.

§ 405.1124 - Oral argument.

§ 405.1126 - Case remanded by the Council.

§ 405.1128 - Action of the Council.

§ 405.1130 - Effect of the Council's decision.

§ 405.1132 - Request for escalation to Federal court.