US Codex
C.F.R.
Browse by date

View an earlier version

Latest
2026-08-27
Browse all versions by date
Notes

42 C.F.R. §§ 417.830–417.840

6 sections in range

§417.830. Scope of regulations on beneficiary appeals.

42 C.F.R. § 417.830

Sections 417.832 through 417.840 establish procedures for the presentation and resolution of organization determinations, reconsiderations, hearings, Departmental Appeals Board review, court reviews, and finality of decisions that are applicable to Medicare enrollees of an HCPP.
Notes, amendments, and revision history

Amendments

[59 FR 59943, Nov. 21, 1994, as amended at 61 FR 32348, June 24, 1996]

Source

Source: 50 FR 1375, Jan. 10, 1985, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

Amendments

[59 FR 59943, Nov. 21, 1994, as amended at 61 FR 32348, June 24, 1996]

§417.832. Applicability of requirements and procedures.

42 C.F.R. § 417.832

(a)
The administrative review rights and procedures specified in §§ 417.834 through 417.840 pertain to disputes involving an organization determination, as defined in § 417.838, with which the enrollee is dissatisfied.
(b)
Physicians and other individuals who furnish items or services under arrangements with an HCPP have no right of administrative review under §§ 417.834 through 417.840.
(c)
The provisions of part 405 dealing with the representation of parties apply to organization determinations and appeals.
(d)
The provisions of part 405 dealing with administrative law judge hearings, Medicare Appeals Council review, and judicial review are applicable, unless otherwise provided.
Notes, amendments, and revision history

Amendments

[59 FR 59943, Nov. 21, 1994, as amended at 70 FR 4713, Jan. 28, 2005]

Source

Source: 50 FR 1375, Jan. 10, 1985, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

Amendments

[59 FR 59943, Nov. 21, 1994, as amended at 70 FR 4713, Jan. 28, 2005]

§417.834. Responsibility for establishing administrative review procedures.

42 C.F.R. § 417.834

The HCPP is responsible for establishing and maintaining the administrative review procedures that are specified in §§ 417.830 through 417.840.
Notes, amendments, and revision history

Amendments

[59 FR 59943, Nov. 21, 1994]

Source

Source: 50 FR 1375, Jan. 10, 1985, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

Amendments

[59 FR 59943, Nov. 21, 1994]

§417.836. Written description of administrative review procedures.

42 C.F.R. § 417.836

Each HCPP is responsible for ensuring that all Medicare enrollees are informed in writing of the administrative review procedures that are available to them.
Notes, amendments, and revision history

Amendments

[59 FR 59943, Nov. 21, 1994]

Source

Source: 50 FR 1375, Jan. 10, 1985, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

Amendments

[59 FR 59943, Nov. 21, 1994]

§417.838. Organization determinations.

42 C.F.R. § 417.838

(a)
Actions that are organization determinations. For purposes of §§ 417.830 through 417.840, an organization determination is a refusal to furnish or arrange for services, or reimburse the party for services provided to the beneficiary, on the grounds that the services are not covered by Medicare.
(b)
Actions that are not organization determinations. The following are not organization determinations for purposes of §§ 417.830 through 417.840:
(1)
A determination regarding services that were furnished by the HCPP, either directly or under arrangement, for which the enrollee has no further obligation for payment.
(2)
A determination regarding services that are not covered under the HCPP's agreement with CMS.
Notes, amendments, and revision history

Amendments

[59 FR 59943, Nov. 21, 1994]

Source

Source: 50 FR 1375, Jan. 10, 1985, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

Amendments

[59 FR 59943, Nov. 21, 1994]

§417.840. Administrative review procedures.

42 C.F.R. § 417.840

The HCPP must apply § 422.568 through § 422.626 of this chapter to—
(a)
Organization determinations and fast-track appeals that affect its Medicare enrollees; and
(b)
Reconsiderations, hearings, Medicare Appeals Council review, and judicial review of the organization determinations and fast-track appeals specified in paragraph (a) of this section.
Notes, amendments, and revision history

Amendments

[75 FR 19803, Apr. 15, 2010]

Source

Source: 50 FR 1375, Jan. 10, 1985, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

Amendments

[75 FR 19803, Apr. 15, 2010]