405.1124 Condition of participation-nurs

ing services.

405.1125 Condition of participation-dietetic services.

405.1126 Condition of participation-specialized rehabilitative services. 405.1127 Condition of participation-pharmaceutical services.

405.1128 Condition of participation-laboratory and radiologic services.

405.1129 Condition of participation-dental services.

405.1130 Condition of participation-social services.

405.1131 Condition of participation-patient activities.

405.1132 Condition of participation-medical records.

405.1133 Condition of participation-transfer agreement.

405.1134 Condition of participation-physical environment.

405.1135 Condition of participation-infection control.

405.1136 Condition of participation-disaster preparedness.

405.1137 Condition of participation—utilization review.

Subpart L-Conditions of Participation; Home Health Agencies

Definitions.

405.1201 General. 405.1202 405.1220 Condition of participation: Compliance with Federal, State, and local laws.

405.1221 Condition of participation: Organization, services, administration. 405.1222 Condition of participation: Group of professional personnel.

405.1223 Condition of participation: Acceptance of patients, plan of treatment, medical supervision.

405.1224 Condition of participation: Skilled nursing service.

405.1225 Condition of participation: Therapy services.

405.1226 Condition of participation: Medical social services.

405.1227 Condition of participation: Home health aide services.

405.1228 Condition of participation: Clinical records.

405.1229 Condition of participation: Evaluation.

405.1230 Condition of participation: Quali

fying to provide outpatient physical therapy or speech pathology services. APPENDIX-Addenda for SEVERAL STATES INCORPORATING CONDITIONS OF PARTICIPATION HIGHER THAN THOSE IMPOSED BY THE HEALTH INSURANCE FOR THE AGED PROGRAM

405.1630

Certification and recertification for beneficiary admitted to a hospital before entitlement to benefits.

405.1632 Posthospital SNF care: Certification and recertification.

405.1633 Home health services; certification and recertification.

405.1634 Medical and other health services furnished by a participating provider or ESRD facility; certification and recertification.

405.1635 Comprehensive outpatient rehabilitation facility (CORF) services. 405.1660 Payment on behalf of the individual; general.

405.1662 Forms used for applying for entitlement or enrollment and 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.

405.1668 Prohibition of assignment of ben

efits by a provider.

405.1672 Individual's request for direct payment-General provisions. 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 Limitation on reassignment of

benefits.

405.1681 Revocation of right to receive assigned benefits.

405.1682 Conditions court-ordered assign

ments and reassignments must meet to be excepted from basic prohibition. 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

405.1701 Conditions of participation-general.

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-compliance 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.

405.1735 Condition for coverage-coordina

tion of services with other organizations, agencies, or individuals.

405.1736 Condition for coverage-clinical records.

405.1737 Condition for coverage-physical

405.1890 Appeals from a determination under section 1122 of the Act.

Subpart S-Certification Procedure for Providers and Suppliers of Services 405.1901 The certification process. 405.1902 State survey agency review. 405.1903 Documentation of findings. 405.1904 Periodic review 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 Temporary waivers applicable to hospitals.

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-[Reserved]

Subpart U-Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services

405.2100 Scope of subpart. 405.2101

Objectives of end-stage renal disease (ESRD) program. 405.2102 Definitions.

405.2110 Designation of ESRD network

areas.

405.2111 Designation of network coordinating councils.

405.2112 Designation of ESRD networks. 405.2113 Medical review board. 405.2114 Relationship of ESRD networks to health care review organizations and to health service planning organizations. 405.2120 Minimal utilization rates: general. 405.2121 Basis for determining minimal utilization rates.

405.2122 Types and duration of classification according to utilization rates. 405.2123 Reporting of utilization rates for

classification.

405.2124 Calculation of utilization rates for comparison with minimal utilization rates(s) and notification of status. 405.2130 Condition: Minimal utilization rates.

405.2131 Condition: Provider status: Renal transplantation center or renal dialysis

center.

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

exclusions.

405.2430 Beneficiary appeals.

EDITORIAL NOTES: 1. Part 405 of Title 20 was transferred into Title 42 at 42 FR 52826, September 30, 1977. As a result of the transfer, all section numbers in this part are remaining the same and now appear as 42 CFR Part 405.

2. Nomenclature changes affecting this Part 405 appear at 38 FR 3597, Feb. 8, 1973; 38 FR 26718, Sept. 25, 1973; 41 FR 51588, Nov. 23, 1976; 42 FR 65113, Dec. 29, 1977; 48 FR 22924, May 23, 1983.

Subpart A-Hospital Insurance Benefits

AUTHORITY: Secs. 1102, 1814, 1815, 1861, 1866(d), and 1871 of the Social Security Act (42 U.S.C. 1302, 1395f, 1395g, 1395x, 1395cc(d), and 1395hh).

§ 405.100 Scope.

This subpart deals only with conditions and procedures for payment of hospital insurance benefits (Part A of Medicare). Provisions dealing with eligibility and entitlement are set forth in Part 408 of this chapter. Provisions dealing with the scope of the benefits are set forth in Part 409 of this chapter.

[48 FR 12535, Mar. 25, 1983]

§ 405.150 Payment for services furnished; general.

Amounts payable under the provisions described in this Subpart A for inpatient hospital services, posthospital extended care services, posthospital home health services or outpatient hospital diagnostic services furnished to an individual are payable, except as provided in §§ 405.152, 405.153, and 405.157, only to a participating provider of services, that is, a provider which has entered in to an agreement with the Secretary under the conditions described in Part 489 of this chapter.

[34 FR 11206, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977 and amended at 50 FR 33030, Aug. 16, 1985]