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CFR

405.926—Actions that are not initial determinations.

Actions that are not initial determinations and are not appealable under this subpart include, but are not limited to—
(a) Any determination for which CMS has sole responsibility, for example—
(1) If an entity meets the conditions for participation in the program;
(2) If an independent laboratory meets the conditions for coverage of services;
(b) The coinsurance amounts prescribed by regulation for outpatient services under the prospective payment system;
(c) Any issue regarding the computation of the payment amount of program reimbursement of general applicability for which CMS or a carrier has sole responsibility under Part B such as the establishment of a fee schedule set forth in part 414 of this chapter, or an inherent reasonableness adjustment pursuant to § 405.502(g), and any issue regarding the cost report settlement process under Part A;
(d) Whether an individual's appeal meets the qualifications for expedited access to judicial review provided in § 405.990 ;
(e) Any determination regarding whether a Medicare overpayment claim must be compromised, or collection action terminated or suspended under the Federal Claims Collection Act of 1966, as amended;
(f) Determinations regarding the transfer or discharge of residents of skilled nursing facilities in accordance with § 483.12 of this chapter ;
(g) Determinations regarding the readmission screening and annual resident review processes required by subparts C and E of part 483 of this chapter ;
(h) Determinations for a waiver of Medicare Secondary Payer recovery under section 1862(b) of the Act;
(i) Determinations for a waiver of interest;
(j) Determinations for a finding regarding the general applicability of the Medicare Secondary Payer provisions (as opposed to the application of these provisions to a particular claim or claims for Medicare payment for benefits);
(k) 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 (directly, as an insurer or self-insurer, as a third party administrator, as an employer that sponsors or contributes to a group health plan or a large group health plan, or otherwise,) to make payment for services or items that were already reimbursed by the Medicare program;
(l) A contractor's, QIC's, ALJ's, or MAC's determination or decision to reopen or not to reopen an initial determination, redetermination, reconsideration, hearing decision, or review decision;
(m) Determinations that CMS or its contractors may participate in or act as parties in an ALJ hearing or MAC review;
(n) Determinations that a provider or supplier failed to submit a claim timely or failed to submit a timely claim despite being requested to do so by the beneficiary or the beneficiary's subrogee;
(o) Determinations with respect to whether an entity qualifies for an exception to the electronic claims submission requirement under part 424 of this chapter ;
(p) Determinations by the Secretary of sustained or high levels of payment errors in accordance with section 1893(f)(3)(A) of the Act;
(q) A contractor's prior determination related to coverage of physicians' services;
(r) Requests for anticipated payment under the home health prospective payment system under § 409.43(c)(ii)(2) of this chapter; and
(s) Claim submissions on forms or formats that are incomplete, invalid, or do not meet the requirements for a Medicare claim and returned or rejected to the provider or supplier.
[70 FR 11472, Mar. 8, 2005, as amended at 70 FR 37702, June 30, 2005]
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