§ 423.558 Scope
§ 423.560 Definitions
§ 423.562 General provisions
§ 423.564 Grievance procedures
§ 423.566 Coverage determinations
§ 423.568 Standard timeframe and notice requirements for coverage determinations
§ 423.570 Expediting certain coverage determinations
§ 423.572 Timeframes and notice requirements for expedited coverage determinations
§ 423.576 Effect of a coverage determination
§ 423.578 Exceptions process
§ 423.580 Right to a redetermination
§ 423.582 Request for a standard redetermination
§ 423.584 Expediting certain redeterminations
§ 423.586 Opportunity to submit evidence
§ 423.590 Timeframes and responsibility for making redeterminations
§ 423.600 Reconsideration by an independent review entity (IRE)
§ 423.602 Notice of reconsideration determination by the independent review entity
§ 423.604 Effect of a reconsideration determination
§ 423.636 How a Part D plan sponsor must effectuate standard redeterminations, reconsiderations, or decisions
§ 423.638 How a Part D plan sponsor must effectuate expedited redeterminations or reconsiderations

Terms Used In CFR > Title 42 > Chapter IV > Subchapter B > Part 423 > Subpart M - Grievances, Coverage Determinations, Redeterminations, and Reconsiderations

  • ALJ: includes a member or members of the Departmental Appeals Board who are designated to conduct a hearing. See 42 CFR 423.1024
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Dismissal: The dropping of a case by the judge without further consideration or hearing. Source:
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.