42 C.F.R. Subpart C—Carriers
Title 42 - Public Health
A contract between CMS and a carrier, other than a regional DMEPOS carrier, specifies the functions to be performed by the carrier which must include, but are not necessarily limited to, the following: (a) Coverage. (1) The carrier ensures that payment is made only for services that are: (i) Furnished to Medicare beneficiaries; (ii) Covered under Medicare; and (iii) In accordance with QIO determinations when they are services for which the QIO has assumed review responsibility under its contract with CMS. (2) The carrier takes appropriate action to reject or adjust the claim if— (i) The carrier or the QIO determines that the services furnished or proposed to be furnished were not reasonable, not medically necessary, or not furnished in the most appropriate setting; (ii) The carrier determines that the claim does not properly reflect the kind and amount of services furnished. (b) Payment on a cost basis. If payment is on a cost basis, the carrier must assure that payments are based on reasonable costs, as determined under part 413 of this chapter. (c) Payment on a charge basis. If payment is on a charge basis, under part 405, subpart E of this chapter, the carrier must ensure that— (1) Charges are reasonable and not higher than the charge for a comparable service furnished under comparable circumstances to the carrier's policy holders and subscribers; and (2) The payment is based on one of the following— (i) An itemized bill. (ii) An assignment under the terms of which the reasonable charge is the full charge for the service, as specified in §424.55 of this chapter. (iii) If the beneficiary has died, the procedures set forth in §§424.62 and 424.64 of this chapter. (d) Fiscal management. The carrier must receive, disburse, and account for funds in making payments under Medicare. (e) Provider audits. The carrier must audit the records of providers to whom it makes Medicare Part B payments to assure that payments are made properly. (f) Utilization patterns. (1) The carrier must have methods and procedures for identifying utilization patterns that deviate from professionally established norms and bring the deviant patterns to the attention of appropriate professional groups. (2) The carrier must assist providers and other persons who furnish Medicare Part B services to— (i) Develop procedures relating to utilization practices; (ii) Make studies of the effectiveness of those procedures and devise methods to improve them; (iii) Apply safeguards against unnecessary utilization of services; and (iv) Develop procedures for utilization review, and establish groups to perform such reviews of providers to whom it makes Medicare Part B payments. (g) Information and reports. The carrier must furnish to CMS any information and reports that CMS requests in order to carry out CMS's responsibilities in the administration of the Medicare program. The carrier must be responsive to requests for information from the public. (h) Maintenance and availability of records. The carrier must maintain and make available to CMS the records necessary for verification of payments and for other related purposes. (i) Hearings to Part B beneficiaries. (1) The carrier must provide an opportunity for a fair hearing if it denies the beneficiary's request for payment, does not act upon the request with reasonable promptness, or pays less than the amount claimed. (2) The hearing procedures must be in accordance with part 405, subpart H, of this chapter (Review and Hearing Under the Supplementary Medical Insurance Program). (j) Other terms and conditions. The carrier must comply with any other terms and conditions included in its contract. [45 FR 42183, June 23, 1980; 45 FR 64913, Oct. 1, 1980, as amended at 49 FR 3660, Jan. 30, 1984; 49 FR 9174, Mar. 12, 1984; 51 FR 34833, Sept. 30, 1986; 51 FR 41350, Nov. 14, 1986; 51 FR 43198, Dec. 1, 1986; 52 FR 4499, Feb. 12, 1987; 53 FR 6648, Mar. 2, 1988; 54 FR 4027, Jan. 27, 1989; 57 FR 27307, June 18, 1992] (a) Application of performance criteria and standards. As part of the carrier evaluations mandated by section 1842(b)(2) of the Act, CMS periodically assesses the performance of carriers in their Medicare operations using performance criteria and standards. (1) The criteria measure and evaluate carrier performance of functional responsibilities such as— (i) Accurate and timely payment determinations; (ii) Responsiveness to beneficiary, physician, and supplier concerns; and (iii) Proper management of administrative funds. (2) The standards evaluate the specific requirements of each functional responsibility or criterion. (b) Basis for criteria and standards. CMS bases the performance criteria and standards on— (1) Nationwide carrier experience; (2) Changes in carrier operations due to fiscal constraints; and (3) CMS's objectives in achieving better performance. (c) Publication of criteria and standards. Before the beginning of each evaluation period, which usually coincides with the Federal fiscal year period of October 1–September 30, CMS publishes the performance criteria and standards as a notice in the [59 FR 682, Jan. 6, 1994] Before entering into or renewing a carrier contract, CMS determines that the carrier— (a) Has the capacity to perform its contractual responsibilities effectively and efficiently; (b) Has the financial responsibility and legal authority necessary to carry out its responsibilities; and (c) Will be able to meet any other requirements CMS considers pertinent, and, if designated a regional DMEPOS carrier, any special requirements for regional carriers under §421.210 of this subpart. [45 FR 42179, June 23, 1980, as amended at 57 FR 27307, June 18, 1992] (a) Failure by a carrier to meet, or demonstrate the capacity to meet, the criteria and standards specified in §421.201 may be grounds for adverse action by the Secretary, such as contract termination or non-renewal. (b) Notwithstanding whether or not a carrier meets the criteria and standards specified in §421.201, if the cost incurred by the carrier to meet its contractual requirements exceeds the amount that CMS finds to be reasonable and adequate to meet the cost which must be incurred by an efficiently and economically operated carrier, those high costs may also be grounds for adverse action. [59 FR 682, Jan. 6, 1994] (a) Cause for termination. The Secretary may terminate a contract with a carrier at any time if he or she determines that the carrier has failed substantially to carry out any material terms of the contract or has performed its function in a manner inconsistent with the effective and efficient administration of the Medicare Part B program. (b) Notice and opportunity for hearing. Upon notification of the Secretary's intent to terminate the contract, the carrier may request a hearing within 20 days after the date on the notice of intent to terminate. (c) Hearing procedures. The hearing procedures will be those specified in §421.128(c). (a) Basis. This section is based on sections 1834(a)(12) and 1834(h) of the Act, which authorize the Secretary to designate one carrier for one or more entire regions to process claims for durable medical equipment, prosthetic devices, prosthetics, orthotics, and other supplies (DMEPOS). This authority has been delegated to CMS. (b) Types of claims. Claims for the following, except for items incident to a physician's professional service as defined in §410.26, incident to a physician's service in a rural health clinic as defined in §405.2413, or bundled into payment to a provider, ambulatory surgical center, or other facility, are processed by the designated carrier for its designated region and not by other carriers— (1) Durable medical equipment (and related supplies) as defined in section 1861(n) of the Act; (2) Prosthetic devices (and related supplies) as described in section 1861(s)(8) of the Act, (including intraocular lenses and parenteral and enteral nutrients, supplies, and equipment, when furnished under the prosthetic device benefit); (3) Orthotics and prosthetics (and related supplies) as described in section 1861(s)(9); (4) Home dialysis supplies and equipment as described in section 1861(s)(2)(F); (5) Surgical dressings and other devices as described in section 1861(s)(5); (6) Immunosuppressive drugs as described in section 1861(s)(2)(J); and (7) Other items or services which are designated by CMS. (c) Region designation. (1) The boundaries of the initial four regions for processing claims described in paragraph (b) of this section contain the following States and territories: (i) Region A: Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York, New Jersey, Pennsylvania, and Delaware. (ii) Region B: Maryland, the District of Columbia, Virginia, West Virginia, Ohio, Michigan, Indiana, Illinois, Wisconsin, and Minnesota. (iii) Region C: North Carolina, South Carolina, Kentucky, Tennessee, Georgia, Florida, Alabama, Mississippi, Louisiana, Texas, Arkansas, Oklahoma, New Mexico, Colorado, Puerto Rico, and the Virgin Islands. (iv) Region D: Alaska, Hawaii, American Samoa, Guam, the Northern Mariana Islands, California, Nevada, Arizona, Washington, Oregon, Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Kansas, Iowa, and Missouri. (2) CMS has the option to modify the number and boundaries of the regions established in paragraph (c)(1) of this section based on appropriate criteria and considerations, including the effect of the change on beneficiaries and DMEPOS suppliers. To announce changes, CMS publishes a notice in the (d) Criteria for designating regional carriers. CMS designates regional carriers to achieve a greater degree of effectiveness and efficiency in the administration of the Medicare program. In making this designation, CMS will award regional carrier contracts in accordance with applicable law and will consider some or all of the following criteria— (1) Timeliness of claim processing; (2) Cost per claim; (3) Claim processing quality; (4) Experience in claim processing, and in establishing local medical review policy; and (5) Other criteria that CMS believes to be pertinent. (e) Carrier designation. (1) Each carrier designated a regional carrier must process claims for items listed in paragraph (b) of this section for beneficiaries whose permanent residence is within that carrier's region as designated under paragraph (c) of this section. When processing the claims, the carrier must use the payment rates applicable for the State of residence of the beneficiary, including a qualified Railroad Retirement beneficiary. A beneficiary's permanent residence is the address at which he or she intends to spend 6 months or more of the calendar year. (2) CMS notifies affected Medicare beneficiaries and suppliers when it designates a regional carrier (in accordance with paragraph (d) of this section) to process DMEPOS claims (as defined in paragraph (b) of this section) for all Medicare beneficiaries residing in their respective regions (as designated under paragraph (c) of this section). (3) CMS may contract for the performance of National Supplier Clearinghouse functions through a contract amendment to one of the DME regional carrier contracts or through a contract amendment to any Medicare carrier contract under §421.200. (4) CMS periodically recompetes the contracts for the DME regional carriers. CMS also periodically recompetes the National Supplier Clearinghouse function. (f) Collecting information of ownership. Carriers designated as regional claims processors must obtain from each supplier of items listed in paragraph (b) of this section information concerning ownership and control as required by section 1124A of the Act and part 420 of this chapter, and certifications that supplier standards are met as required by part 424 of this chapter. [57 FR 27307, June 18, 1992, as amended at 58 FR 60796, Nov. 18, 1993; 70 FR 9239, Feb. 25, 2005] In accordance with this subpart C, the Railroad Retirement Board contracts with DMEPOS regional carriers designated by CMS, as set forth in §421.210(e)(2), for processing claims for Medicare-eligible Railroad Retirement beneficiaries, for the same contract period as the contracts entered into between CMS and the DMEPOS regional carriers. [58 FR 60797, Nov. 18, 1993] (a) Scope and applicability. This section provides for the following: (1) Sets forth requirements and procedures for the issuance and recovery of advance payments to suppliers of Part B services and the rights and responsibilities of suppliers under the payment and recovery process. (2) Does not limit CMS's right to recover unadjusted advance payment balances. (3) Does not affect suppliers' appeal rights under part 405, subpart H of this chapter relating to substantive determinations on suppliers' claims. (4) Does not apply to claims for Part B services furnished by suppliers that have in effect provider agreements under section 1866 of the Act and part 489 of this chapter, and are paid by intermediaries. (b) Definition. As used in this section, advance payment means a conditional partial payment made by the carrier in response to a claim that it is unable to process within established time limits. (c) When advance payments may be made. An advance payment may be made if all of the following conditions are met: (1) The carrier is unable to process the claim timely. (2) CMS determines that the prompt payment interest provision specified in section 1842(c) of the Act is insufficient to make a claimant whole. (3) CMS approves, in writing to the carrier, the making of an advance payment by the carrier. (d) When advance payments are not made. Advance payments are not made to any supplier that meets any of the following conditions: (1) Is delinquent in repaying a Medicare overpayment. (2) Has been advised of being under active medical review or program integrity investigation. (3) Has not submitted any claims. (4) Has not accepted claims' assignments within the most recent 180-day period preceding the system malfunction. (e) Requirements for suppliers. (1) Except as provided for in paragraph (g)(1) of this section, a supplier must request, in writing to the carrier, an advance payment for Part B services it furnished. (2) A supplier must accept an advance payment as a conditional payment subject to adjustment, recoupment, or both, based on an eventual determination of the actual amount due on the claim and subject to the provisions of this section. (f) Requirements for carriers. (1) A carrier must notify a supplier as soon as it is determined that payment will not be made in a timely manner, and an advance payment option is to be offered to the supplier. (i) A carrier must calculate an advance payment for a particular claim at no more than 80 percent of the anticipated payment for that claim based upon the historical assigned claims payment data for claims paid the supplier. (ii) “Historical data” are defined as a representative 90-day assigned claims payment trend within the most recent 180-day experience before the system malfunction. (iii) Based on this amount and the number of claims pending for the supplier, the carrier must determine and issue advance payments. (iv) If historical data are not available or if backlogged claims cannot be identified, the carrier must determine and issue advance payments based on some other methodology approved by CMS. (v) Advance payments can be made no more frequently than once every 2 weeks to a supplier. (2) Generally, a supplier will not receive advance payments for more assigned claims than were paid, on a daily average, for the 90-day period before the system malfunction. (3) A carrier must recover an advance payment by applying it against the amount due on the claim on which the advance was made. If the advance payment exceeds the Medicare payment amount, the carrier must apply the unadjusted balance of the advance payment against future Medicare payments due the supplier. (4) In accordance with CMS instructions, a carrier must maintain a financial system of data in accordance with the Statement of Federal Financial Accounting Standards for tracking each advance payment and its recoupment. (g) Requirements for CMS. (1) In accordance with the provisions of this section, CMS may determine that circumstances warrant the issuance of advance payments to all affected suppliers furnishing Part B services. CMS may waive the requirement in paragraph (e)(1) of this section as part of that determination. (2) If adjusting Medicare payments fails to recover an advance payment, CMS may authorize the use of any other recoupment method available (for example, lump sum repayment or an extended repayment schedule) including, upon written notice from the carrier to the supplier, converting any unpaid balances of advance payments to overpayments. Overpayments are recovered in accordance with part 401, subpart F of this chapter concerning claims collection and compromise and part 405, subpart C of this chapter concerning recovery of overpayments. (h) Prompt payment interest. An advance payment is a “payment” under section 1842(c)(2)(C) of the Act for purposes of meeting the time limit for the payment of clean claims, to the extent of the advance payment. (i) Notice, review, and appeal rights. (1) The decision to advance payments and the determination of the amount of any advance payment are committed to CMS's discretion and are not subject to review or appeal. (2) The carrier must notify the supplier receiving an advance payment about the amounts advanced and recouped and how any Medicare payment amounts have been adjusted. (3) The supplier may request an administrative review from the carrier if it believes the carrier's reconciliation of the amounts advanced and recouped is incorrectly computed. If a review is requested, the carrier must provide a written explanation of the adjustments. (4) The review and explanation described in paragraph (i)(3) of this section is separate from a supplier's right to appeal the amount and computation of benefits paid on the claim, as provided at part 405, subpart H of this chapter. The carrier's reconciliation of amounts advanced and recouped is not an initial determination as defined at §405.803 of this chapter, and any written explanation of a reconciliation is not subject to further administrative review. [61 FR 49275, Sept. 19, 1996]
Title 42: Public Health
PART 421—INTERMEDIARIES AND CARRIERS
Subpart C—Carriers
§ 421.200 Carrier functions.
§ 421.201 Performance criteria and standards.
§ 421.202 Requirements and conditions.
§ 421.203 Carrier's failure to perform efficiently and effectively.
§ 421.205 Termination by the Secretary.
§ 421.210 Designations of regional carriers to process claims for durable medical equipment, prosthetics, orthotics and supplies.
§ 421.212 Railroad Retirement Board contracts.
§ 421.214 Advance payments to suppliers furnishing items or services under Part B.
