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42 CFR 405.926 Update

42 CFR §405.900 establishes the requirements for appeals of initial determinations for benefits under Part A or Part B of Medicare. Under the regulations, the Medicare contractor makes an initial determination when a claim for Medicare benefits under Part A or B is submitted. A beneficiary who is dissatisfied with the initial determination may go through an appeals process.

This regulation also includes a provision that details the actions that are not initial determinations and are not appealable, CFR §405.926. Recently, this section was updated to include the following action that does not qualify as an initial determination: “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.” 42 CFR 405.926.

Other actions that do not qualify as initial determinations include determinations for a waiver of Medicare Secondary Payer recovery under section 1862(b) of the Act, determinations for a finding regarding the general applicability of the Medicare Secondary Payer provisions, and 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 to make payment for services or items that were already reimbursed by the Medicare program. 42 CFR 405.926.

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