Short answer Where do Medicaid managed care rules actually live? Medicaid managed care rules live in title 42 of the Code of Federal Regulations, part 438, which holds eleven subparts. Grievances and appeals sit in subpart F. The rule on who may deny a service sits at section 438.210, inside subpart D. Hunting a rule …
WASHINGTON – Medicare began reviewing a list of procedures in advance in six states on 1 January 2026. The companies that grant or refuse that review are paid out of money Medicare does not spend. That is not an allegation. It is in the government’s own notice. The Federal Register notice says participants are “compensated …
What Medicare’s AI Prior Authorization Pilot Actually Does Read More »
Short answer Which five parts decide what Medicare pays? Five parts of Title 42 carry most Medicare payment questions. Part 405 holds claims and appeals, part 409 hospital benefits, part 410 doctor and outpatient benefits, part 422 Medicare Advantage, part 424 the conditions for payment. Part 424 names 409 and 410 by number. Somewhere in …
WASHINGTON – The Electronic Frontier Foundation reports thousands of refusals in the first three months of Medicare’s machine assisted approval programme. It reports one request that waited 83 days. Those figures do not show whether the programme refuses payment more often than a person would. The two numbers that would settle that have not been …
Do AI Reviews Raise Denial Rates? The Figures Cannot Say Read More »
Short answer How do you tell whether a document is actually a rule? A document that explains a rule is not the rule. The test is public comment: a legislative rule must be published for notice and comment, while interpretative rules and policy statements are exempt. Guidance that binds nobody can still decide your claim, …
Short answer What are the two federal rulebooks? There are two federal rulebooks. The Code of Federal Regulations holds what a rule says today, arranged by subject. The Federal Register holds every change in date order, with the agency’s reasoning attached. Use the first to read the rule and the second to learn when it …
Short answer Which version of the rulebook are you reading? Three versions of the same rule exist at once. The printed edition is official and reprints once a year, with Medicare titles frozen each October. The online version updates daily but is unofficial. The Federal Register carries changes as they happen. Cite the printed edition …
WASHINGTON – A Medicare claim must be worth at least $200 next year before an administrative law judge will hear an appeal of it. CMS published the figure on 16 September 2026. The notice says the amounts apply to requests “filed on or after January 1, 2027.” There is a second line above it. To …
Short answer What is the difference between a grievance and an appeal? A grievance is a complaint about anything other than a denial. An appeal challenges the denial itself. Filing the wrong one can cost the deadline, because an appeal must be requested within 60 calendar days of the denial notice while a grievance has …
SILVER SPRING, MD – Software that reads your medical scan and flags what it finds must still pass an FDA check before it is sold. The agency put that on the public record on Thursday. A company had asked for the check to be dropped in certain cases, and the answer was no. The order …
The FDA Refused to Let Scan Software Skip Its Safety Check Read More »
