[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR498.20]



[Page 1095]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 498_APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT PARTICIPATION 

IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS THAT AFFECT THE 

PARTICIPATION OF ICFs/MR AND CERTAIN NFs IN THE MEDICAID PROGRAM--Table 

of Contents

 

       Subpart B_Initial, Reconsidered, and Revised Determinations

 

Sec. 498.20  Notice and effect of initial determinations.





    (a) Notice of initial determination--(1) General rule. CMS or the 

OIG, as appropriate, mails notice of an initial determination to the 

affected party, setting forth the basis or reasons for the 

determination, the effect of the determination, and the party's right to 

reconsideration, if applicable, or to a hearing.

    (2) Special rules: Independent laboratories and suppliers of 

portable x-ray services. If CMS determines that an independent 

laboratory or a supplier of portable x-ray services no longer meets the 

conditions for coverage of some or all of its services, the notice--

    (i) Specifies an effective date of termination of coverage that is 

at least 15 days after the date of the notice;

    (ii) Is also sent to physicians, hospitals, and other parties that 

might use the services of the laboratory or supplier; and

    (iii) In the case of laboratories, specifies the categories of 

laboratory tests that are no longer covered.

    (3) Special rules: Nonparticipating hospitals that elect to claim 

payment for emergency services. If CMS determines that a 

nonparticipating hospital no longer qualifies to elect to claim payment 

for all emergency services furnished in a calendar year, the notice--

    (i) States the calendar year to which the determination applies;

    (ii) Specifies an effective date that is at least 5 days after the 

date of the notice; and

    (iii) Specifies that the determination applies to services 

furnished, in the specified calendar year, to patients accepted (as 

inpatients or outpatients) on or after the effective date of the 

determination.

    (4) Other special rules. Additional rules pertaining, for example, 

to content and timing of notice, notice to the public and to other 

entities, and time allowed for submittal of additional information, are 

set forth elsewhere in this chapter, as follows:



Part 405 Subpart X--for rural health clinics.

Part 416--for ambulatory surgical centers.

Part 489--for providers, when their provider agreements have been 

terminated.

Part 1001, Subpart B--for excluded or suspended providers, suppliers, 

physicians, or practitioners.

Part 1001, Subpart C--for providers, when their provider agreements are 

terminated by the OIG.

Part 1004--for sanctioned providers and practitioners.



    (b) Effect of initial determination. An initial determination is 

binding unless it is--

    (1) Reconsidered in accordance with Sec. 498.24;

    (2) Reversed or modified by a hearing decision in accordance with 

Sec. 498.78; or

    (3) Revised in accordance with Sec. 498.32 or Sec. 498.100.