Sec.

405.1630 Certification and recertification

for beneficiary admitted to a hospital before entitlement to benefits. 405.1632 Post-hospital extended care services; certification and recertification. 405.1633 Home health services; certification and recertification. 405.1634 Medical and other health services covered by the supplementary medical insurance program furnished by a provider of services; certification and recertification.

405.1660 Payment on behalf of the individual; general.

405.1662 Form used for claiming payment. 405.1663 Individual's request for payment. 405.1664 Persons authorized to request payment.

405.1665 Evidence of authority to execute a request for payment. 405.1666 Signature by representative of the participating provider or hospital. 405.1667 Claim for payment by a provider

of services or a hospital which has elected to claim payment for emergency services or services outside the United States. 405.1672 Individual's request for direct payment-General.

405.1674 Individual's request for direct

payment; evidence describing services. 405.1675 Assignment of right to receive

payment under the supplementary medical insurance benefits plan. 405.1678 Direct payment or assignment of payment; prescribed form.

405.1679 Execution of claim for payment. 405.1680 Payment of assigned benefits. 405.1683 Payment on the basis of a paid

bill; individual dies before receiving direct payment.

405.1684 Payment on the basis of an

unpaid bill; individual dies before receiving direct payment or assigning payment. 405.1685 Payment to organizations that pay bills on behalf of enrollees. 405.1686 Organizations qualified to receive payment on behalf of enrollee. 405.1692 Time limitation for claiming benefits payable on a reasonable charge basis.

405.1693 Definition of claim for purposes of time limitation.

405.1694 Extension of time limitation. 405.1695 Replacement of U.S. Government

checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.

405.1696 Replacement of intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.

405.1697 Reclamation proceedings in cases of forgery of intermediary and carrier checks.

Subpart Q-Conditions of Participation: Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and/or Speech Pathology Services; and Conditions for Coverage: Outpatient Physical Therapy Services Furnished by Physical Therapists in Independent Practice CONDITIONS OF PARTICIPATION: CLINICS, REHABILITATION AGENCIES, AND PUBLIC HEALTH AGENCIES AS PROVIDERS OF OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES

Sec.

405.1701 Conditions of participation-general.

405.1702 Definitions relating to clinics, rehabilitation agencies, and public health agencies.

405.1715 Condition of participation-compliance with Federal, State, and local laws.

405.1716 Condition of participation-administrative management.

405.1717 Condition of participation-physician's direction and plan of care. 405.1718 Condition of participation-physical therapy services.

405.1719 Condition of participationspeech pathology services.

405.1720 Condition of participation-rehabilitation program.

405.1721 Condition of participation-ar

rangements for physical therapy and

speech pathology services to be performed by other than salaried organization personnel.

405.1722 Condition of participation-clinical records.

405.1723 Condition of participation-physical environment.

405.1724 Condition of participation-infection control.

405.1725 Condition of participation-disaster preparedness.

405.1726 Condition of participation-program evaluation.

CONDITIONS FOR COVERAGE: OUTPATIENT PHYSICAL THERAPY SERVICES FURNISHED BY PHYSICAL THERAPISTS IN INDEPENDENT PRACTICE

405.1730 Conditions for coverage-Services furnished by physical therapists in independent practice-General. 405.1731 Definitions relating to physical therapists in independent practice. 405.1732 Condition for coverage-compli

ance with Federal, State, and local laws. 405.1733 Condition for coverage-physician's direction and plan of care. 405.1734 Condition for coverage-physical therapy services.

405.1819 Conduct of intermediary hearing. 405.1821 Prehearing discovery and other proceedings prior to the intermediary hearing.

405.1823 Evidence at intermediary hearing. 405.1825 Witnesses at intermediary hearing.

405.1827 Record of intermediary hearing. 405.1829 Authority of hearing officer(s) at intermediary hearing.

405.1831 Intermediary hearing decision and notice.

405.1833 Effect of intermediary hearing decision.

405.1835 Board hearing; right to Board hearing.

405.1837 Group appeal.

405.1839 Amount in controversy.

405.1841 Time, place, form, and content of request for Board hearing.

405.1843 Parties to Board hearing. 405.1845 Composition of Board.

405.1847 Disqualification of Board members.

405.1849 Establishment of time and place of hearing by the Board.

405.1851 Conduct of Board hearing. 405.1853 Prehearing discovery and other proceedings prior to the Board hearing. 405.1855 Evidence at Board hearing. 405.1857 Subpoenas.

405.1901 405.1902 405.1903

The certification process. Certification by State agency. Documentation of findings. 405.1904 Periodic certification of compliance and approval.

405.1905 Certification of noncompliance. 405.1906 Determining compliance. 405.1907 Providers or suppliers with deficiencies.

405.1908 Special requirements applicable to skilled nursing facilities with deficiencies.

405.1909 Special requirements applicable to independent laboratories. 405.1910 Special hospital certification. 405.1911 Special waivers applicable to skilled nursing facilities.

405.1912 Special procedures for approving end-stage renal disease facilities and the expansion of services in approved facilities.

405.1913 Remote facility variances for utilization review requirements.

Subpart T-Health Maintenance Organizations 405.2001 Health maintenance organiza

tions; general.

405.2002 Qualifying conditions: General. 405.2003 Qualifying conditions: Public Health Service Act requirements. 405.2004 Qualifying condition: Membership.

405.2005 Qualifying condition: Range of services.

405.2007 Qualifying condition: Provision of services.

405.2020

HMO enrollment. 405.2021 Health insurance program beneficiary's entitlement to items and services. 405.2022 Liability of a health insurance program beneficiary enrolled in an HMO.

405.2023 Enrollment procedures. 405.2024 Membership rules.

Subpart X-Rural Health Clinic Services

405.2401 Scope and definitions. 405.2402 Basic requirements.

405.2403 Content and terms of the agreement with the Secretary.

405.2404 Terminations of agreements. 405.2410 Beneficiary entitlement and liability.

405.2411 Scope of benefits. 405.2412 Physicians' services.

405.2413 Services and supplies incident to a physician's services.

405.2414 Nurse practitioner and physician assistant services.

405.2415 Services and supplies incident to

nurse practitioner and physician assistant services.

405.2416 Visiting nurse services. 405.2417 Visiting nurse services: Determination of shortage of agencies. 405.2418 Applicability of general payment

§ 405.102 Hospital insurance benefits for individuals age 65 or over.

(a) Conditions of entitlement. An individual is entitled to hospital insur

ance benefits under the provisions described in this Subpart A if such individual has attained age 65 and:

(1) Is entitled to monthly insurance benefits under section 202 of the Social Security Act as described in Subpart D of 20 CFR Part 404; or

(2) Is a "qualified railroad retirement beneficiary" as described in paragraph (b) of this section; or

(3) Is deemed entitled to monthly insurance benefits under section 202 of the Social Security Act, solely for purposes of entitlement to hospital insurance benefits, by meeting the requirements prescribed in § 405.103.

(b) Qualified railroad retirement beneficiary. For purposes of this Part 405, the term "qualified railroad retirement beneficiary" means an individual whose name has been certified to the Social Security Administration by the Railroad Retirement Board under section 7(d) of the Railroad Retirement Act of 1974. An individual shall cease to be a qualified railroad retirement beneficiary at the close of the month preceding the month which is certified by the Railroad Retirement Board as the month in which he ceases to meet the requirements of section 7(d) of the Railroad Retirement Act of 1974.

(c) Beginning of coverage. An individual is entitled to hospital insurance benefits beginning with the first day of the first month after June 1966 for which he meets the conditions of paragraph (a) of this section.

(d) End of coverage—(1) General. An individual's entitlement to hospital insurance benefits under paragraph (a) of this section ends with whichever occurs first:

(i) The last day of the month in which he dies; or

(ii) The last day of the month before the month he no longer meets the requirements:

(A) For entitlement to monthly benefits under section 202 of the Social Security Act;

(B) of section 7(d) of the Railroad Retirement Act of 1974, if qualified for hospital insurance benefits solely as a qualified railroad retirement beneficiary; or

(C) of the transitional provisions on eligibility for hospital insurance bene

fits (see § 405.103) because such individual has become entitled to monthly benefits under section 202 of the Social Security Act or has been certified as a qualified railroad retirement beneficiary.

(2) Deemed entitlement in the month of death. For purposes of paragraph (d)(1) of this section, an individual will be deemed to have been entitled to a monthly insurance benefit under section 202 of the Social Security Act, or to have been a qualified railroad retirement beneficiary, for the month in which he died if he would have been entitled to a monthly insurance benefit under section 202 of the Act, or would have been a qualified railroad retirement beneficiary, for such month had he died in the next month. [40 FR 24357, June 6, 1975. Redesignated at 42 FR 52826, Sept. 30, 1977]

§ 405.103 Transitional provisions for entitlement of aged uninsured individuals to hospital insurance benefits. (a) Requirements. Unless excluded under the provisions of paragraph (b) of this section, an individual age 65 or over will be deemed entitled to monthly insurance benefits under section 202 of the Social Security Act, solely for purposes of entitlement to hospital insurance benefits (see § 405.102(a)(3)), if such individual:

or

(1) (i) Attained age 65 before 1968,

(ii) Attained age 65 after 1967 and has not less than three quarters of coverage (as defined in Subpart B of 20 CFR Part 404 or in section (5)(1) of the Railroad Retirement Act of 1937), whenever acquired, for each calendar year after 1966 and before the year he attained age 65;

(2) Is not entitled to hospital insurance benefits as provided in § 405.102(a)(1) and would not be entitled to such benefits upon filing an application for monthly insurance benefits under section 202 of the Social Security Act;

(3) Is not certifiable as a qualified railroad retirement beneficiary (see § 405.102(a)(2));

(4) Is a resident of the United States (for definition of United States see 20 CFR 404.2(c)(6)), and