CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER B—MEDICARE PROGRAM (parts 405 to 426) > PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS > SUBPART U—Health Care Prepayment Plans (§417.800 to §417.840) > 417.838—Organization determinations.

417.838—Organization determinations.

(a) Actions that are organization determinations. For purposes of §§ 417.830 through 417.840, an organization determination is a refusal to furnish or arrange for services, or reimburse the party for services provided to the beneficiary, on the grounds that the services are not covered by Medicare.
(b) Actions that are not organization determinations. The following are not organization determinations for purposes of §§ 417.830 through 417.840:
(1) A determination regarding services that were furnished by the HCPP, either directly or under arrangement, for which the enrollee has no further obligation for payment.
(2) A determination regarding services that are not covered under the HCPP's agreement with CMS.
[59 FR 59943, Nov. 21, 1994]