42 C.F.R. PART 424—CONDITIONS FOR MEDICARE PAYMENT
Title 42 - Public Health
Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).
Source: 53 FR 6634, Mar. 2, 1988, unless otherwise noted.
Link to an amendment published at 71 FR 48409, Aug. 18, 2006. (a) Statutory basis. (1) This part is based on the indicated provisions of the following sections of the Act:
1814—Basic conditions for, and limitations on, Medicare payments for Part A services. 1815—Payment to providers for Part A services. 1820—Conditions for designating certain hospitals as critical assess hospitals. 1833(e)—Requirement to furnish information to determine payment. 1835—Procedures for payment to providers for Part B services. 1842(b)(3)(B)(ii)—Assignment of Part B Medicare claims. 1842(b)(6)—Payment to entities other than the supplier. 1848—Payment for physician services. 1870(e) and (f)—Settlement of claims after death of the beneficiary. (2) Section 424.444(c) is also based on section 216(j) of the Act. (b) Scope. This part sets forth certain specific conditions and limitations applicable to Medicare payments and cites other conditions and limitations set forth elsewhere in this chapter. This subpart A provides a general overview. Other subparts deal specifically with— (1) The requirement that the need for services be certified and that a physician establish a plan of treatment (subpart B); (2) The procedures and time limits for filing claims (subpart C); (3) The individuals or entities to whom payment may be made (subparts D and E); (4) The limitations on assignment and reassignment of claims (subpart F); (5) Special requirements that apply to services furnished by nonparticipating U.S. hospitals and foreign hospitals (subparts G and H); and (6) The replacement and reclamation of Medicare payment checks (subpart M). (c) Other applicable rules. Except for §424.40(c)(3), this part does not deal with the conditions for payment of rural health clinic (RHC) services, Federally qualified health center (FQHC) services, or ambulatory surgical center (ASC) services. Those conditions are set forth in part 405, subpart X, and part 481 subpart A of this chapter for RHC and FQHC services; and in part 416 of this chapter, for ASC services. The rules for physician certification of terminal illness, required in connection with hospice care, are set forth in §418.22 of this chapter. [53 FR 6634, Mar. 2, 1988, as amended at 60 FR 38271, July 26, 1995; 60 FR 50442, Sept. 29, 1995; 62 FR 46035, Aug. 29, 1997; 71 FR 20775, Apr. 21, 2006] As used in this part, unless the context indicates otherwise— HCPCS means Healthcare Common Procedure Coding System. ICD–9–CM means International Classification of Diseases, Ninth Revision, Clinical Modification. Nonparticipating hospital means a hospital that does not have in effect a provider agreement to participate in Medicare. Participating hospital means a hospital that has in effect a provider agreement to participate in Medicare. [53 FR 6634, Mar. 2, 1988, as amended at 59 FR 10299, Mar. 4, 1994; 63 FR 26311, May 12, 1998; 70 FR 45055, Aug. 4, 2005] (a) As a basis for Medicare payment, the following conditions must be met: (1) Types of services. The services must be— (i) Covered services, as specified in part 409 or part 410 of this chapter; or (ii) Services excluded from coverage as custodial care or services not reasonable and necessary, but reimbursable in accordance with §§405.332 through 405.334 of this chapter, pertaining to limitation of liability. (2) Sources of services. The services must have been furnished by a provider, nonparticipating hospital, or supplier that was, at the time it furnished the services, qualified to have payment made for them. (3) Recipient of services. Except as provided in §409.68 of this chapter, the services must have been furnished while the individual was eligible to have payment made for them. (Section 409.68 provides for payment of inpatient hospital services furnished before the hospital is notified that the beneficiary has exhausted the Medicare benefits available for the current benefit period.) (4) Certification of need for services. When required, the provider must obtain certification and recertification of the need for the services in accordance with subpart B of this part. (5) Claim for payment. The provider, supplier, or beneficiary, as appropriate, must file a claim that includes or makes reference to a request for payment, in accordance with subpart C of this part. (6) Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. (b) Additional conditions applicable in certain circumstances or to certain services are set forth in other sections of this part. [53 FR 6635, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 60 FR 38271, July 26, 1995] (a) Utilization review finding on medical necessity. When a QIO or a UR committee notifies a hospital or SNF of its finding that further services are not medically necessary, the following rules apply: (1) Hospitals subject to PPS. Payment may not be made for inpatient hospital services furnished by a PPS hospital after the second day after the day on which the hospital received the notice. (2) Hospitals not subject to PPS and SNFs—(i) Basic rule. Except as provided in paragraph (a)(2)(ii) of this section, payment may not be made for inpatient hospital services or posthospital SNF care furnished after the day on which the hospital or SNF received the notice. (ii) Exception. Payment may be made for 1 or 2 additional days if the QIO or UR committee approves them as necessary for planning for post-discharge care. (b) Failure to make timely utilization review. Payment may not be made for inpatient hospital services or posthospital SNF care furnished, after the 20th consecutive day of a stay, to an individual who is admitted to the hospital or SNF after CMS has determined that the hospital or SNF has failed to make timely utilization review in long stay cases. (This provision does not apply to a hospital or SNF for which a QIO has assumed binding review.) [53 FR 6635, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988] (a) Purpose. The physician has a major role in determining utilization of health services furnished by providers. The physician decides upon admissions, orders tests, drugs, and treatments, and determines the length of stay. Accordingly, sections 1814(a)(2) and 1835(a)(2) of the Act establish as a condition for Medicare payment that a physician certify the necessity of the services and, in some instances, recertify the continued need for those services. Section 1814(a)(2) of the Act also permits nurse practitioners or clinical nurse specialists to certify and recertify the need for post-hospital extended care services. (b) Scope. This subpart sets forth the timing, content, and signature requirements for certification and recertification with respect to certain Medicare services furnished by providers. [60 FR 38271, July 26, 1995] (a) Responsibility of the provider. The provider must— (1) Obtain the required certification and recertification statements; (2) Keep them on file for verification by the intermediary, if necessary; and (3) Certify, on the appropriate billing form, that the statements have been obtained and are on file. (b) Obtaining the certification and recertification statements. No specific procedures or forms are required for certification and recertification statements. The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form. Except as provided in paragraph (d) of this section for delayed certifications, there must be a separate signed statement for each certification or recertification. (c) Required information. The succeeding sections of this subpart set forth specific information required for different types of services. If that information is contained in other provider records, such as physicians' progress notes, it need not be repeated. It will suffice for the statement to indicate where the information is to be found. (d) Timeliness. (1) The succeeding sections of this subpart also specify the time frames for certifications and for initial and subsequent recertifications. (2) A hospital or SNF may provide for obtaining a certification or recertification earlier than required by these regulations, or vary the time frame (within the prescribed outer limits) for different diagnostic or clinical categories. (3) Delayed certification and recertification statements are acceptable when there is a legitimate reason for delay. (For instance, the patient was unaware of his or her entitlement when he or she was treated.) Delayed certification and recertification statements must include an explanation of the reason for the delay. (4) A delayed certification may be included with one or more recertifications on a single signed statement. (e) Limitation on authorization to sign statements. A certification or recertification statement may be signed only by one of the following: (1) A physician who is a doctor of medicine or osteopathy. (2) A dentist in the circumstances specified in §424.13(c). (3) A doctor of podiatric medicine if his or her certification is consistent with the functions he or she is authorized to perform under State law. (4) A nurse practitioner or clinical nurse specialist, as defined in paragraph (e)(5) or (e)(6) of this section, in the circumstances specified in §424.20(e). (5) For purposes of this section, to qualify as a nurse practitioner, an individual must— (i) Be a registered professional nurse who is currently licensed to practice nursing in the State where he or she practices; be authorized to perform the services of a nurse practitioner in accordance with State law; and have a master's degree in nursing; (ii) Be certified as a nurse practitioner by a professional association recognized by CMS that has, at a minimum, eligibility requirements that meet the standards in paragraph (e)(5)(i) of this section; or (iii) Meet the requirements for a nurse practitioner set forth in paragraph (e)(5)(i) of this section, except for the master's degree requirement, and have received before August 25, 1998 a certificate of completion from a formal advanced practice program that prepares registered nurses to perform an expanded role in the delivery of primary care. (6) For purposes of this section, to qualify as a clinical nurse specialist, an individual must— (i) Be a registered professional nurse who is currently licensed to practice nursing in the State where he or she practices; be authorized to perform the services of a clinical nurse specialist in accordance with State law; and have a master's degree in a defined clinical area of nursing; (ii) Be certified as a clinical nurse specialist by a professional association recognized by CMS that has at a minimum, eligibility requirements that meet the standards in paragraph (e)(6)(i) of this section; or (iii) Meet the requirements for a clinical nurse specialist set forth in paragraph (e)(6)(i) of this section, except for the master's degree requirement, and have received before August 25, 1998 a certificate of completion from a formal advanced practice program that prepares registered nurses to perform an expanded role in the delivery of primary care. [53 FR 6634, Mar. 2, 1988, as amended at 56 FR 8845, Mar. 1, 1991; 60 FR 38272, July 26, 1995] (a) Content of certification and recertification. Medicare Part A pays for inpatient hospital services of hospitals other than psychiatric hospitals only if a physician certifies and recertifies the following: (1) The reasons for either— (i) Continued hospitalization of the patient for medical treatment or medically required inpatient diagnostic study; or (ii) Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F of part 412 of this chapter). (2) The estimated time the patient will need to remain in the hospital. (3) The plans for posthospital care, if appropriate. (b) Certification of need for hospitalization when a SNF bed is not available. (1) A physician may certify or recertify need for continued hospitalization if the physician finds that the patient could receive proper treatment in a SNF but no bed is available in a participating SNF. (2) If this is the basis for the physician's certification or recertification, the required statement must so indicate; and the physician is expected to continue efforts to place the patient in a participating SNF as soon as a bed becomes available. (c) Signatures—(1) Basic rule. Except as specified in paragraph (c)(2) of this section, certifications and recertifications must be signed by the physician responsible for the case, or by another physician who has knowledge of the case and who is authorized to do so by the responsible physician or by the hospital's medical staff. (2) Exception. If the intermediary requests certification of the need to admit a patient in connection with dental procedures, because his or her underlying medical condition and clinical status or the severity of the dental procedures require hospitalization, that certification may be signed by the dentist caring for the patient. (d) Timing of certifications and recertifications: Cases not subject to the prospective payment system (PPS). (1) For cases that are not subject to PPS, certification is required no later than as of the 12th day of hospitalization. A hospital may, at its option, provide for the certification to be made earlier, or it may vary the timing of the certification within the 12-day period by diagnostic or clinical categories. (2) The first recertification is required no later than as of the 18th day of hospitalization. (3) Subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses), but no less frequently than every 30 days. (e) Timing of certification and recertification: Cases subject to PPS. For cases subject to PPS, certification is required as follows: (1) For day-outlier cases, certification is required no later than one day after the hospital reasonably assumes that the case meets the outlier criteria, established in accordance with §412.80(a)(1)(i) of this chapter, or no later than 20 days into the hospital stay, whichever is earlier. The first and subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses) but not less frequently than every 30 days. (2) For cost-outlier cases, certification is required no later than the date on which the hospital requests cost outlier payment or 20 days into the hospital stay, whichever is earlier. If possible, certification must be made before the hospital incurs costs for which it will seek cost outlier payment. In cost outlier cases, the first and subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses). (f) Recertification requirement fulfilled by utilization review. (1) At the hospital's option, extended stay review by its UR committee may take the place of the second and subsequent physician recertifications required for cases not subject to PPS and for PPS day-outlier cases. (2) A utilization review that is used to fulfill the recertification requirement is considered timely if performed no later than the seventh day after the day the physician recertification would have been required. The next physician recertification would need to be made no later than the 30th day following such review; if review by the UR committee took the place of this physician recertification, the review could be performed as late as the seventh day following the 30th day. (g) Description of procedures. The hospital must have available on file a written description that specifies the time schedule for certifications and recertifications, and indicates whether utilization review of long-stay cases fulfills the requirement for second and subsequent recertifications of all cases not subject to PPS and of PPS day outlier cases. (a) Content of certification and recertification: General considerations. The content requirements differ from those for other hospitals because the care furnished in psychiatric hospitals is often purely custodial and thus not covered under Medicare. The purpose of the statements, therefore, is to help ensure that Medicare pays only for services of the type appropriate for Medicare coverage. Accordingly, Medicare Part A pays for inpatient care in a psychiatric hospital only if a physician certifies and recertifies the need for services consistent with the content of paragraphs (b) or (c) of this section, as appropriate. (b) Content of certification. Inpatient psychiatric services were required— (1) For treatment that could reasonably be expected to improve the patient's condition; or (2) For diagnostic study. (c) Content of recertification. (1) Inpatient services furnished since the previous certification or recertification were, and continue to be, required— (i) For treatment that could reasonably be expected to improve the patient's condition; or (ii) For diagnostic study; and (2) The hospital records show that the services furnished were— (i) Intensive treatment services; (ii) Admission and related services necessary for diagnostic study; or (iii) Equivalent services. (3) The patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel. (d) Timing of certification and recertification. (1) Certification is required at the time of admission or as soon thereafter as is reasonable and practicable. (2) The first recertification is required as of the 12th day of hospitalization. Subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses), but no less frequently than every 30 days. (e) Other requirements. Psychiatric hospitals must also meet the requirements set forth in §424.13 (b), (c), (f), and (g). [53 FR 6634, Mar. 2, 1988, as amended at 71 FR 27087, May 9, 2006; 71 FR 37504, June 30, 2006] (a) Content of certification. Medicare Part A pays for inpatient CAH services only if a physician certifies that the individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH. (b) Timing of certification. Certification is required no later than 1 day before the date on which the claim for payment for the inpatient CAH services is submitted. [58 FR 30671, May 26, 1993, as amended at 60 FR 45850, Sept. 1, 1995; 62 FR 46035, 46037, Aug. 29, 1997] (a) Basic rule. If an indivdual is admitted to a hospital before becoming entitled to Medicare benefits (for instance, before attaining age 65), the day of entitlement (instead of the day of admission) is the starting point for the time limits specified in §424.13(e) for certification and recertification. (b) Example. (Hospital that is not a psychiatric hospital and is not subject to PPS). For a patient who is admitted on August 15 and becomes entitled on September 1— (1) The certification is required no later than September 12; (2) The first recertification is required no later than September 18; and (3) Subsequent recertifications are required at least every 30 days after September 18. [53 FR 6635, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988] Medicare Part A pays for posthospital SNF care furnished by an SNF, or a hospital or CAH with a swing-bed approval, only if the certification and recertification for services are consistent with the content of paragraph (a) or (c) of this section, as appropriate. (a) Content of certification—(1) General requirements. Posthospital SNF care is or was required because— (i) The individual needs or needed on a daily basis skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services that, as a practical matter, can only be provided in an SNF or a swing-bed hospital on an inpatient basis, and the SNF care is or was needed for a condition for which the individual received inpatient care in a participating hospital or a qualified hospital, as defined in §409.3 of this chapter; or (ii) The individual has been correctly assigned to one of the Resource Utilization Groups designated as representing the required level of care, as provided in §409.30 of this chapter. (2) Special requirement for certifications performed prior to July 1, 2002: A swing-bed hospital with more than 49 beds (but fewer than 100) that does not transfer a swing-bed patient to a SNF within 5 days of the availability date. Transfer of the extended care patient to the SNF is not medically appropriate. (b) Timing of certification—(1) General rule. The certification must be obtained at the time of admission or as soon thereafter as is reasonable and practicable. (2) Special rules for certain swing-bed hospitals. For swing-bed hospitals with more than 49 beds that are approved after March 31, 1988, the extended care patient's physician has 5 days (excluding weekends and holidays) beginning on the availability date as defined in §413.114(b), to certify that the transfer of the extended care patient is not medically appropriate. (c) Content of recertifications. (1) The reasons for the continued need for posthopsital SNF care: (2) The estimated time the individual will need to remain in the SNF; (3) Plans for home care, if any; and (4) If appropriate, the fact that continued services are needed for a condition that arose after admission to the SNF and while the individual was still under treatment for the condition for which he or she had received inpatient hospital services. (d) Timing of recertifications. (1) The first recertification is required no later than the 14th day of posthospital SNF care. (2) Subsequent recertifications are required at least every 30 days after the first recertification. (e) Signature. Certification and recertification statements may be signed by— (1) The physician responsible for the case or, with his or her authorization, by a physician on the SNF staff or a physician who is available in case of an emergency and has knowledge of the case; or (2) A nurse practitioner or clinical nurse specialist, neither of whom has a direct or indirect employment relationship with the facility but who is working in collaboration with a physician. For purposes of this section— (i) Collaboration means a process whereby a nurse practitioner or clinical nurse specialist works with a doctor of medicine or osteopathy to deliver health care services. The services are delivered within the scope of the nurse's professional expertise, with medical direction and appropriate supervision as provided for in guidelines jointly developed by the nurse and the physician or other mechanisms defined by Federal regulations and the law of the State in which the services are performed. (ii) A direct employment relationship with the facility is one in which the nurse practitioner or clinical nurse specialist meets the common law definition of the facility's “employee,” as specified in §404.1005, §404.1007, and §404.1009 of title 20 of the regulations. When a nurse practitioner or clinical nurse specialist meets this definition with respect to an entity other than the facility itself, and that entity has an agreement with the facility for the provision of nursing services under §409.21 of this subchapter, the facility is considered to have an indirect employment relationship with the nurse practitioner or clinical nurse specialist. An indirect employment relationship does not exist if the agreement between the entity and the facility involves only the performance of delegated physician tasks under §483.40(e) of this chapter. (f) Recertification requirement fulfilled by utilization review. A SNF may substitute utilization review of extended stay cases for the second and subsequent recertifications, if it includes this procedure in its utilization review plan. (g) Description of procedures. The SNF must have available on file a written description that specifies the certification and recertification time schedule and indicates whether utilization review is used as an alternative to the second and subsequent recertifications. [53 FR 6634, Mar. 2, 1988, as amended at 54 FR 37275, Sept. 7, 1989; 58 FR 30671, May 26, 1993; 60 FR 38272, July 26, 1995; 62 FR 46037, Aug. 29, 1997; 63 FR 26311, May 12, 1998; 63 FR 53307, Oct. 5, 1998; 66 FR 39600, July 31, 2001; 70 FR 45055, Aug. 4, 2005] Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate. (a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify as follows: (i) The individual needs or needed intermittent skilled nursing care, or physical or speech therapy, or (for the period from July through November 30, 1981) occupational therapy. (ii) Home health services were required because the individual was confined to the home except when receiving outpatient services. (iii) A plan for furnishing the services has been established and is periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.) (iv) The services were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.1 1 As a condition of Medicare Part A payment for home health services furnished before July 1981, the physician was also required to certify that the services were needed for a condition for which the individual had received inpatient hospital or SNF services. (2) Timing and signature. The certification of need for home health services must be obtained at the time the plan of treatment is established or as soon thereafter as possible and must be signed by the physician who establishes the plan. (b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days, preferably at the time the plan is reviewed, and must be signed by the physician who reviews the plan of care. The recertification is required at least every 60 days when there is a— (i) Beneficiary elected transfer; or (ii) Discharge and return to the same HHA during the 60-day episode. (2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical or speech therapy. (c) [Reserved] (d) Limitation on the performance of certification and plan of treatment functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of treatment may not be established and reviewed, by any physician who has a financial relationship, as defined in §411.354 of this chapter, with that HHA, unless the physician's relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements. [53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70335, Nov. 21, 2005] (a) Exempted services. Certification is not required for the following: (1) Hospital services and supplies incident to physicians' services furnished to outpatients. The exemption applies to drugs and biologicals that cannot be self-administered, but not to partial hospitalization services, as set forth in paragraph (e) of this section. (2) Outpatient hospital diagnostic services, including necessary drugs and biologicals, ordinarily furnished or arranged for by a hospital for the purpose of diagnostic study. (b) General rule. Medicare Part B pays for medical and other health services furnished by providers (and not exempted under paragraph (a) of this section) only if a physician certifies the content specified in paragraph (c)(1), (c)(4) or (e)(1) of this section, as appropriate. (c) Outpatient physical therapy and speech-language pathology services—(1) Content of certification. (i) The individual needs, or needed, physical therapy or speech pathology services. (ii) The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant. (iii) The services were furnished under a plan of treatment that meets the requirements of §410.61 of this chapter. (2) Timing. The certification statement must be obtained at the time the plan of treatment is established, or as soon thereafter as possible. (3) Signature. (i) If the plan of treatment is established by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, the certification must be signed by that physician or nonphysician practitioner. (ii) If the plan of treatment is established by a physical therapist or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case. (4) Recertification—(i) Timing. Recertification statements are required at least every 30 days and must be signed by the physician, nurse practitioner, clinical nurse specialist, or physician assistant who reviews the plan of treatment. (ii) Content. The recertification statement must indicate the continuing need for physical therapy or speech-language pathology services and an estimate of how much longer the services will be needed. (iii) Signature. Recertifications must be signed by the physician, nurse practitioner, clinical nurse specialist, or physician assistant who reviews the plan of treatment. (d) [Reserved] (e) Partial hospitalization services: Content of certification and plan of treatment requirements—(1) Content of certification. (i) The individual would require inpatient psychiatric care if the partial hospitalization services were not provided. (ii) The services are or were furnished while the individual was under the care of a physician. (iii) The services were furnished under a written plan of treatment that meets the requirements of paragraph (e)(2) of this section. (2) Plan of treatment requirements. (i) The plan is an individualized plan that is established and is periodically reviewed by a physician in consultation with appropriate staff participating in the program, and that sets forth— (A) The physician's diagnosis; (B) The type, amount, duration, and frequency of the services; and (C) The treatment goals under the plan. (ii) The physician determines the frequency and duration of the services taking into account accepted norms of medical practice and a reasonable expectation of improvement in the patient's condition. (3) Recertification requirements—(i) Signature. The physician recertification must be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment. (ii) Timing. The first recertification is required as of the 18th day of partial hospitalization services. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days. (iii) Content. The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the partial hospitalization program and describe the following: (A) The patient's response to the therapeutic interventions provided by the partial hospitalization program. (B) The patient's psychiatric symptoms that continue to place the patient at risk of hospitalization. (C) Treatment goals for coordination of services to facilitate discharge from the partial hospitalization program. (f) All other covered medical and other health services furnished by providers—(1) Content of certification. The services were medically necessary, (2) Signature. The certificate must be signed by a physician, nurse practioner, clinical nurse specialist, or physician assistant who has knowledge of the case. (3) Timing. The physician, nurse practioner, clinical nurse specialist, or physician assistant may provide certification at the time the services are furnished or, if services are provided on a continuing basis, either at the beginning or at the end of a series of visits. (4) Recertification. Recertification of continued need for services is not required. [53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, 8853, Mar. 1, 1991; 63 FR 58912, Nov. 2, 1998; 65 FR 18548, Apr. 7, 2000] Medicare Part B pays for CORF services only if a physician certifies, and the facility physician recertifies, the content specified in paragraphs (a) and (b)(2) of this section, as appropriate. (a) Certification: Content. (1) The services were required because the individual needed skilled rehabilitation services; (2) The services were furnished while the individual was under the care of a physician; and (3) A written plan of treatment has been established and is reviewed periodically by a physician. (b) Recertification—(1) Timing. Recertification is required at least every 60 days, based on review by a facility physician who, when appropriate, consults with the professional personnel who furnish the services. (2) Content. (i) The plan is being followed; (ii) The patient is making progress in attaining the rehabilitation goals; and, (iii) The treatment is not having any harmful effect on the patient. This subpart sets forth the requirements, procedures, and time limits for claiming Medicare payments. Claims must be filed in all cases except when services are furnished on a prepaid capitation basis by a health maintenance organization (HMO), a competitive medical plan (CMP), or a health care prepayment plan (HCPP). Special procedures for claiming payment after the beneficiary has died and for certain bills paid by organizations are set forth in subpart E of this part. [53 FR 6639, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988]
Link to an amendment published at 71 FR 48143, Aug. 18, 2006. (a) A claim must meet the following requirements: (1) A claim must be filed with the appropriate intermediary or carrier on a form prescribed by CMS in accordance with CMS instructions. (2) A claim for physician services, clinical psychologist services, or clinical social worker services must include appropriate diagnostic coding for those services using ICD–9–CM. (3) A claim must be signed by the beneficiary or the beneficiary's representative (in accordance with §424.36(b)). (4) A claim must be filed within the time limits specified in §424.44. (5) All Part B claims for services furnished to SNF residents (whether filed by the SNF or by another entity) must include the SNF's Medicare provider number and appropriate HCPCS coding. (b) The prescribed forms for claims are the following:
CMS–1450—Uniform Institutional Provider Bill. (This form is for institutional provider billing for Medicare inpatient, outpatient and home health services.) CMS–1490S—Request for Medicare payment. (For use by a patient to request payment for medical expenses.) CMS–1490U—Request for Medicare Payment by Organization. (For use by an organization requesting payment for medical services.) CMS–1491—Request for Medicare Payment-Ambulance. (For use by an organization requesting payment for ambulance services.) CMS–1500—Health Insurance Claim Form. (For use by physicians and other suppliers to request payment for medical services.) CMS–1660—Request for Information-Medicare Payment for Services to a Patient now Deceased. (For use in requesting amounts payable under title XVIII to a deceased beneficiary.) (c) Where claims forms are available. Excluding forms CMS–1450 and CMS–1500, all claims forms prescribed for use in the Medicare program are distributed free-of-charge to the public, institutions, or organizations. The CMS–1450 and CMS–1500 may be obtained only by commercial purchase. All other claims forms can be obtained upon request from CMS or any Social Security branch or district office, or from Medicare intermediaries or carriers. The CMS–1490S is also available at local Social Security Offices. (d) Submission of electronic claims—(1) Definitions. For purposes of this paragraph, the following terms have the following meanings: (i) Claim means a transaction defined at 45 CFR 162.1101(a). (ii) Electronic claim means a claim that is submitted via electronic media. A claim submitted via direct data entry is considered to be an electronic claim. (iii) Direct data entry is defined at 45 CFR 162.103. (iv) Electronic media is defined at 45 CFR 160.103. (v) Initial Medicare claim means a claim submitted to Medicare for payment under Part A or Part B of the Medicare Program under title XVIII of the Act for initial processing, including claims sent to Medicare for the first time for secondary payment purposes. Initial Medicare claim excludes any adjustment or appeal of a previously submitted claim, and claims submitted for payment under Part C of the Medicare program under title XVIII of the Act. (vi) Physician, practitioner, facility, or supplier is a Medicare provider or supplier other than a provider of services. (vii) Provider of services means a provider of services as defined in section 1861(u) of the Act. (viii) Small provider of services or small supplier means— (A) A provider of services with fewer than 25 full-time equivalent employees; or (B) A physician, practitioner, facility, or supplier with fewer than 10 full-time equivalent employees. (2) Submission of electronic claims required. Except for claims to which paragraph (d)(3) or (d)(4) of this section applies, an initial Medicare claim may be paid only if submitted as an electronic claim for processing by the Medicare fiscal intermediary or carrier that serves the physician, practitioner, facility, supplier, or provider of services. This requirement does not apply to any other transactions, including adjustment or appeal of the initial Medicare claim. (3) Exceptions to requirement to submit electronic claims. The requirement of paragraph (d)(2) of this section is waived for any initial Medicare claim when— (i) There is no method available for the submission of an electronic claim. This exception includes claims submitted by Medicare beneficiaries and situations in which the standard adopted by the Secretary at 45 FR 162.1102 does not support all of the information necessary for payment of the claim. The Secretary may identify situations coming within this exception in guidance. (ii) The entity submitting the claim is a small provider of services or small supplier. (4) Unusual cases. The Secretary may waive the requirement of paragraph (d)(2) of this section in unusual cases as the Secretary finds appropriate. Unusual cases are deemed to exist in the following situations: (i) The submission of dental claims. (ii) There is a service interruption in the mode of submitting the electronic claim that is outside the control of the entity submitting the claim, for the period of the interruption. (iii) The entity submitting the claim submits fewer than 10 claims to Medicare per month, on average. (iv) The entity submitting the claim only furnishes services outside of the U.S. territory. (v) On demonstration, satisfactory to the Secretary, of other extraordinary circumstances precluding submission of electronic claims. (5) Effective date. This paragraph (d) is effective October 16, 2003, and applies to claims submitted on or after October 16, 2003. [53 FR 6639, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988, as amended at 59 FR 10299, Mar. 4, 1994; 63 FR 26311, May 12, 1998; 63 FR 53307, Oct. 5, 1998; 66 FR 39601, July 31, 2001; 68 FR 48813, Aug. 15, 2003; 70 FR 71020, Nov. 25, 2005] All claims for services of providers and all claims by suppliers and nonparticipating hospitals must be— (a) Filed by the provider, supplier, or hospital; and (b) Signed by the provider, supplier, or hospital unless CMS instructions waive this requirement. (a) Basic rule. A beneficiary's claim for direct payment for services furnished by a supplier, or by a nonparticipating hospital that has not elected to claim payment for emergency services, must include an itemized bill or a “report of services”, as specified in paragraphs (b) and (c) of this section. (b) Itemized bill from the hospital or supplier. The itemized bill for the services, which may be receipted or unpaid, must include all of the following information: (1) The name and address of— (i) The beneficiary; (ii) The supplier or nonparticipating hospital that furnished the services; and (iii) The physician who prescribed the services if they were furnished by a supplier other than the physician. (2) The place where each service was furnished, e.g., home, office, independent laboratory, hospital. (3) The date each service was furnished. (4) A listing of the services in sufficient detail to permit determination of payment under the fee schedule for physicians' services; for itemized bills from physicians, appropriate diagnostic coding using ICD–9–CM must be used. (5) The charges for each service. (c) Report of services furnished by a supplier. For Medicare Part B services furnished by a supplier, the beneficiary claims may include the “Report of Services” portion of the appropriate claims form, completed by the supplier in accordance with CMS instructions, in lieu of an itemized bill. [53 FR 6634, Mar. 2, 1988, as amended at 59 FR 10299, Mar. 4, 1994; 59 FR 26740, May 24, 1994] (a) General rule. The beneficiary's own signature is required on the claim unless the beneficiary has died or the provisions of paragraph (b), (c), or (d) of this section apply. (b) Who may sign when the beneficiary is incapable. If the beneficiary is physically or mentally incapable of signing the claim, the claim may be signed on his or her behalf by one of the following: (1) The beneficiary's legal guardian. (2) A relative or other person who receives social security or other governmental benefits on the beneficiary's behalf. (3) A relative or other person who arranges for the beneficiary's treatment or exercises other responsibility for his or her affairs. (4) A representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services, or assistance to the beneficiary. (5) A representative of the provider or of the nonparticipating hospital claiming payment for services it has furnished if the provider or nonparticipating hospital is unable to have the claim signed in accordance with paragraph (b) (1), (2), (3), or (4) of this section. (c) Who may sign if the beneficiary was not present for the service. If a provider, nonparticipating hospital, or supplier files a claim for services that involved no personal contact between the provider, hospital, or supplier and the beneficiary (for example, a physician sent a blood sample to the provider for diagnostic tests), a representative of the provider, hospital, or supplier may sign the claim on the beneficiary's behalf. (d) Claims by entities that provide coverage complementary to Medicare. A claim by an entity that provides coverage complementary to Medicare Part B may be signed by the entity on the beneficiary's behalf. (e) Acceptance of other signatures for good cause. If good cause is shown, CMS may honor a claim signed by a party other than those specified in paragraphs (a) through (c) of this section. [53 FR 6640, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988, as amended at 53 FR 28388, July 28, 1988] (a) Beneficiary incapable. When a party specified in §424.36(b) signs a claim or request for payment statement, he or she must also submit a brief statement that— (1) Describes his or her relationship to the beneficiary; and (2) Explains the circumstances that make it impractical for the beneficiary to sign the claim or statement. (b) Beneficiary not present for services. When a representative of the provider, nonparticipating hospital, or supplier signs a claim or request for payment statement under §424.36(c), he or she must explain why it was not possible to obtain the beneficiary's signature. (For example: “Patient not physically present for test.”) [53 FR 6640, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988] (a) Basic procedure. A separate request for payment statement prescribed by CMS and signed by the beneficiary (or by his or her representative) may be included in claims by reference, in the circumstances specified in paragraphs (b) through (d) of this section. (b) Claims filed by a provider or nonparticipating hospital—(1) Inpatient services. A signed request for payment statement, included in the first claim for Part A services furnished by a facility (a participating hospital or SNF, or a nonparticipating hospital that has elected to claim payment) during a beneficiary's period of confinement, may be effective for all claims for Part A services the facility furnishes that beneficiary during that confinement. (2) Home health services and outpatient physical therapy or speech pathology services. A signed request for payment statement, included in the first claim for home health services or outpatient physical therapy or speech pathology services furnished by a provider under a plan of treatment, may be effective for all claims for home health services or outpatient physical therapy or speech pathology services furnished by the provider under that plan of treatment. (c) Signed statement in the provider record—(1) Services to inpatients. A signed request for payment statement in the files of a participating hospital or SNF may be effective for all claims for services furnished to the beneficiary during a single inpatient stay in that facility— (i) By the hospital or SNF; (ii) By physicians, if their services are billed by the hospital or SNF in its name; or (iii) By physicians who bill separately, if the services were furnished in the hospital or SNF. (2) Services to outpatients: Providers and renal dialysis facilities. A signed request for payment statement retained in the provider's or facility's files may be effective indefinitely, for all claims for services furnished to that beneficiary on an outpatient basis— (i) By the provider or facility; (ii) By physicians whose services are billed by the provider or facility in its name; or (iii) By physicians who bill separately, if the services were furnished in the provider or facility. (3) Services to outpatients: Independent rural health clinics and Federally qualified health centers. A signed request for payment statement retained in the clinic's or center's files may be effective indefinitely for all claims for services furnished to that beneficiary by the clinic. (d) Signed statement in the supplier's record. A signed request for payment statement retained in the supplier's file may be effective indefinitely subject to the following restrictions: (1) This policy does not apply to unassigned claims for rental of durable medical equipment (DME). (2) With respect to assigned claims for rental or purchase of DME, a new statement is required if another item of equipment is rented or purchased. [53 FR 6634, Mar. 2, 1988, as amended at 57 FR 24982, June 12, 1992] (a) Basic limits. Except as provided in paragraph (b) of this section, the claim must be mailed or delivered to the intermediary or carrier, as appropriate— (1) On or before December 31 of the following year for services that were furnished during the first 9 months of a calendar year; and (2) On or before December 31 of the second following year for services that were furnished during the last 3 months of the calendar year. (b) Extension of filing time because of error or misrepresentation. (1) The time for filing a claim will be extended if failure to meet the deadline in paragraph (a) of this section was caused by error or misrepresentation of an employee, intermediary, carrier, or agent of the Department that was performing Medicare functions and acting within the scope of its authority. (2) The time will be extended through the last day of the 6th calendar month following the month in which the error or misrepresentation is corrected. (c) Extension of period ending on a nonworkday. If the last day of the period allowed under paragraph (a) or (b) of this section falls on a Federal nonworkday (a Saturday, Sunday, legal holiday, or a day which by statute or Executive Order is declared to be a nonworkday for Federal employees), the time is extended to the next succeeding workday. (d) Outpatient diabetes self-management training. CMS makes payment in half-hour increments to an entity for the furnishing of outpatient diabetes self-management training on or after the approval date CMS approves the entity to furnish the services under part 410, subpart H of this chapter. [53 FR 6634, Mar. 2, 1988, as amended at 65 FR 83153, Dec. 29, 2000] (a) This subpart specifies to whom Medicare payment is ordinarily made for different kinds of services. (b) Subpart E of this part sets forth provisions applicable in special situations. (c) Subpart F of this part specifies the exceptional circumstances under which payment may be made to an assignee or reassignee. (a) Basic rule. Except as specified in paragraph (b) of this section, Medicare pays the provider for services furnished by a provider. (b) Exception. Medicare pays the beneficiary for outpatient hospital services if the hospital has collected an amount in excess of the unmet deductible and coinsurance, as specified in §489.30(b)(4) of this chapter. Medicare pays a nonparticipating hospital for the following services, if covered, in the specified circumstances: (a) Emergency inpatient and outpatient services furnished by a U.S. hospital, if the hospital has in effect an election to claim payment in accordance with subpart G of this part. (b) Certain medical and other health services covered under Medicare Part B and furnished by a U.S. hospital, if the hospital meets the requirements of §424.55 for payment as a supplier. (c) Emergency or nonemergency inpatient services furnished by a foreign hospital if the hospital has in effect an election to claim payment in accordance with subpart G of this part. Medicare pays the beneficiary for the following services, if covered, in the specified circumstances: (a) Emergency inpatient and outpatient services furnished by a nonparticipating U.S. hospital that has not elected to claim payment in accordance with subpart G of this part. (b) Certain medical and other health services covered under Medicare Part B and furnished by a nonparticipating U.S. hospital, if the hospital does not receive assigned payment as a supplier under §424.55. (c) Emergency or nonemergency services furnished by a foreign hospital if the hospital does not have in effect an election to claim payment in accordance with subpart H of this part. (d) Physician and ambulance services furnished outside the United States. (e) Services furnished by a supplier if the claim has not been assigned to the supplier. Medicare may pay amounts due a beneficiary to the beneficiary's legal guardian or representative payee. (a) Medicare pays the supplier for covered services if the beneficiary (or the person authorized to request payment on the beneficiary's behalf) assigns the claim to the supplier and the supplier accepts assignment. (b) In accepting assignment, the supplier agrees to the following: (1) To accept, as full charge for the service, the amount approved by the carrier as the basis for determining the Medicare Part B payment (the reasonable charge or the lesser of the fee schedule amount and the actual charge). (2) To limit charges to the beneficiary or any other source as follows: (i) To collect nothing for those services for which Medicare pays 100 percent of the Medicare approved amount. (ii) To collect only the difference between the Medicare approved amount and the Medicare Part B payment (for example, the amount of any reduction in incurred expenses under §410.155(c), any applicable deductible amount, and any applicable coinsurance amount) for services for which Medicare pays less than 100 percent of the approved amount. (3) Not to charge the beneficiary when Medicare paid for services determined to be “not reasonable or necessary” if— (i) The beneficiary was without fault in the overpayment; and (ii) The determination that the payment was incorrect was made by the carrier after the third year following the year in which the carrier sent notice to the beneficiary that it approved the payment. (c) Exception. In situations when payment under the Act can only be made on an assignment-related basis or when payment is for services furnished by a participating physician or supplier, the beneficiary (or the person authorized to request payment on the beneficiary's behalf) is not required to assign the claim to the supplier in order for an assignment to be effective. [53 FR 6634, Mar. 2, 1988, as amended at 63 FR 20130, Apr. 23, 1998; 69 FR 66426, Nov. 15, 2004] (a) Conditions for split payment. If the beneficiary assigns the claim after paying part of the bill, payment may be made partly to the beneficiary and partly to the supplier. (b) Payment to the supplier. Payment to the supplier who submits the assigned claim is for whichever of the following amounts is less: (1) The reasonable charge minus the amount the beneficiary had already paid to the supplier; or (2) The full Part B benefit due for the services furnished. (c) Payment to the beneficiary. Any part of the Part B benefit which, on the basis of paragraph (b) of this section, is not payable to the supplier, is paid to the beneficiary. (d) Examples. Example 1. An assigned bill of $300 on which partial payment of $100 has been made is submitted to the carrier. The carrier determines that $300 is the reasonable charge for the service furnished. Total payment due is 80 percent of $300 or $240. Of this amount, $200 (the difference between the $100 partial payment and the $300 reasonable charge) is paid to the supplier. The remaining $40 is paid to the beneficiary. Example 2. An assigned bill of $325 on which partial payment of $275 has been made is submitted to the carrier. The carrier determines that $275 is the reasonable charge for the services. Total payment due is 80 percent of $275 or $220. The $220 is paid to the beneficiary, since any payment to the supplier, when added to the $275 partial payment would exceed the reasonable charge for the services furnished. [53 FR 6641, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988]
Link to an amendment published at 71 FR 48409, Aug. 18, 2006. (a) Definitions. As used in this section, the following definitions apply: DMEPOS stands for durable medical equipment, prosthetics, orthotics and supplies. DMEPOS supplier means an entity or individual, including a physician or a Part A provider, which sells or rents Part B covered items to Medicare beneficiaries and which meets the standards in paragraph (c) of this section. Medicare covered items means medical equipment and supplies as defined in section 1834(j)(5) of the Act. (b) General rule. A DMEPOS supplier must meet the following conditions in order to be eligible to receive payment for a Medicare-covered item: (1) The supplier has submitted a completed application to CMS to furnish Medicare-covered items including required enrollment forms. (The supplier must enroll separate physical locations it uses to furnish Medicare-covered DMEPOS, with the exception of locations that it uses solely as warehouses or repair facilities.) (2) The item was furnished on or after the date CMS issued to the supplier a DMEPOS supplier number conveying billing privileges. (CMS issues only one supplier number for each location.) This requirement does not apply to items furnished incident to a physician's service. (3) CMS has not revoked or excluded the DMEPOS supplier's privileges during the period which the item was furnished has not been revoked or excluded. (4) A supplier that furnishes a drug used as a Medicare-covered supply with durable medical equipment or prosthetic devices must be licensed by the State to dispense drugs (A supplier of drugs must bill and receive payment for the drug in its own name. A physician, who is enrolled as a DMEPOS supplier, may dispense, and bill for, drugs under this standard if authorized by the State as part of the physician's license.) (5) The supplier has furnished to CMS all information or documentation required to process the claim. (c) Application certification standards. The supplier must meet and must certify in its application for billing privileges that it meets and will continue to meet the following standards. The supplier: (1) Operates its business and furnishes Medicare-covered items in compliance with all applicable Federal and State licensure and regulatory requirements; (2) Has not made, or caused to be made, any false statement or misrepresentation of a material fact on its application for billing privileges. (The supplier must provide complete and accurate information in response to questions on its application for billing privileges. The supplier must report to CMS any changes in information supplied on the application within 30 days of the change.); (3) Must have the application for billing privileges signed by an individual whose signature binds a supplier; (4) Fills orders, frabicates, or fits items from its own inventory or by contracting with other companies for the purchase of items necessary to fill the order. If it does, it must provide, upon request, copies of contracts or other documentation showing compliance with this standard. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal Government Executive Branch procurement or nonprocurement program or activity; (5) Advises beneficiaries that they may either rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental durable medical equipment, as defined in §414.220(a) of this subchapter. (The supplier must provide, upon request, documentation that it has provided beneficiaries with this information, in the form of copies of letters, logs, or signed notices.); (6) Honors all warranties expressed and implied under applicable State law. A supplier must not charge the beneficiary or the Medicare program for the repair or replacement of Medicare covered items or for services covered under warranty. This standard applies to all purchased and rented items, including capped rental items, as described in §414.229 of this subchapter. The supplier must provide, upon request, documentation that it has provided beneficiaries with information about Medicare covered items covered under warranty, in the form of copies of letters, logs, or signed notices; (7) Maintains a physical facility on an appropriate site. The physical facility must contain space for storing business records including the supplier's delivery, maintenance, and beneficiary communication records. For purposes of this standard, a post office box or commercial mailbox is not considered a physical facility. In the case of a multi-site supplier, records may be maintained at a centralized location; (8) Permits CMS, or its agents to conduct on-site inspections to ascertain supplier compliance with the requirements of this section. The supplier location must be accessible during reasonable business hours to beneficiaries and to CMS, and must maintain a visible sign and posted hours of operation; (9) Maintains a primary business telephone listed under the name of the business locally or toll-free for beneficiaries. The supplier must furnish information to beneficiaries at the time of delivery of items on how the beneficiary can contact the supplier by telephone. The exclusive use of a beeper number, answering service, pager, facsimile machine, car phone, or an answering machine may not be used as the primary business telephone for purposes of this regulation; (10) Has a comprehensive liability insurance policy in the amount of at least $300,000 that covers both the supplier's place of business and all customers and employees of the supplier. In the case of a supplier that manufactures its own items, this insurance must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in revocation of the supplier's billing privileges retroactive to the date the insurance lapsed; (11) Must agree not to contact a beneficiary by telephone when supplying a Medicare-covered item unless one of the following applies: (i) The individual has given written permission to the supplier to contact them by telephone concerning the furnishing of a Medicare-covered item that is to be rented or purchased. (ii) The supplier has furnished a Medicare-covered item to the individual and the supplier is contacting the individual to coordinate the delivery of the item. (iii) If the contact concerns the furnishing of a Medicare-covered item other than a covered item already furnished to the individual, the supplier has furnished at least one covered item to the individual during the 15-month period preceding the date on which the supplier makes such contact. (12) Must be responsible for the delivery of Medicare covered items to beneficiaries and maintain proof of delivery. (The supplier must document that it or another qualified party has at an appropriate time, provided beneficiaries with necessary information and instructions on how to use Medicare-covered items safely and effectively); (13) Must answer questions and respond to complaints a beneficiary has about the Medicare-covered item that was sold or rented. A supplier must refer beneficiaries with Medicare questions to the appropriate carrier. A supplier must maintain documentation of contacts with beneficiaries regarding complaints or questions; (14) Must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. The item must function as required and intended after being repaired or replaced; (15) Must accept returns from beneficiaries of substandard (less than full quality for the particular item or unsuitable items, inappropriate for the beneficiary at the time it was fitted and rented or sold); (16) Must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item; (17) Must comply with the disclosure provisions in §420.206 of this subchapter; (18) Must not convey or reassign a supplier number; (19) Must have a complaint resolution protocol to address beneficiary complaints that relate to supplier standards in paragraph (c) of this section and keep written complaints, related correspondence and any notes of actions taken in response to written and oral complaints. Failure to maintain such information may be considered evidence that supplier standards have not been met. (This information must be kept at its physical facility and made available to CMS, upon request.); (20) Must maintain the following information on all written and oral beneficiary complaints, including telephone complaints, it receives: (i) The name, address, telephone number, and health insurance claim number of the beneficiary. (ii) A summary of the complaint; the date it was received; the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint. (iii) If an investigation was not conducted, the name of the person making the decision and the reason for the decision. (21) Provides to CMS, upon request, any information required by the Medicare statute and implementing regulations. (d) Failure to meet standards. CMS will revoke a supplier's billing privileges if it is found not to meet the standards in paragraphs (b) and (c) of this section. (The revocation is effective 15 days after the entity is sent notice of the revocation, as specified in §405.874 of this subchapter.) (e) Renewal of billing privileges. A supplier must renew its application for billing privileges every 3 years after the billing privileges are first granted. (Each supplier must complete a new application for billing privileges 3 years after its last renewal of privileges.) [65 FR 60377, Oct. 11, 2000]
Link to an amendment published at 71 FR 48409, Aug. 18, 2006. (a) This subpart sets forth provisions applicable to payment after the beneficiary's death and payment to entities that provide coverage complementary to Medicare Part B. (b) The provisions applicable to payment for services excluded as custodial care or services not reasonable and necessary are set forth in §§405.332 through 405.336 of this chapter. [53 FR 6634, Mar. 2, 1988, as amended at 53 FR 28388, July 28, 1988] (a) Scope. This section specifies the persons whom Medicare pays, and the conditions for payments, when the beneficiary has died and the bill has been paid. (b) Situation. (1) The beneficiary has received covered services for which he could receive direct payment under §424.53. (2) The beneficiary died without receiving Medicare payment. (3) The bill has been paid. (c) Persons whom Medicare pays. In the situation described in paragraph (b) of this section, Medicare pays the following persons in the specified circumstances: (1) The person or persons who, without a legal obligation to do so, paid for the services with their own funds, before or after the beneficiary's death. (2) The legal representative of the beneficiary's estate if the services were paid for by the beneficiary before he or she died, or with funds from the estate. (3) If the deceased beneficiary or his or her estate paid for the services and no legal representative of the estate has been appointed, the survivors, in the following order of priority: (i) The person found by SSA to be the surviving spouse, if he or she was either living in the same household with the deceased at the time of death, or was, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary; (ii) The child or children, who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child); (iii) The parent or parents, who were, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent); (iv) The person found by SSA to be the surviving spouse who was not living in the same household with the deceased at the time of death and was not, for the month of death, entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased beneficiary; (v) The child or children who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one child, in equal parts to each child); (vi) The parent or parents who were not entitled to monthly social security or railroad retirement benefits on the basis of the same earnings record as the deceased (and, if there is more than one parent, in equal parts to each parent). (4) If none of the listed relatives survive, no payment is made. (5) If the services were paid for by a person other than the deceased beneficiary, and that person died before payment was completed, Medicare does not pay that person's estate. Medicare pays a surviving relative of the deceased beneficiary in accordance with the priorities in paragraph (c)(3) of this section. If none of those relatives survive. Medicare pays the legal representative of the deceased beneficiary's estate. If there is no legal representative of the estate, no payment is made. (d) Amount of payment. The amount of payment is the amount due, including unnegotiated checks issued for the purpose of making direct payment to the beneficiary. (e) Conditions for payment. For payment to be made under this section— (1) The person who claims payment must meet the following requirements: (i) Submit a claim on a CMS-prescribed form and an itemized bill in accordance with the requirements of this subpart. (See paragraph (g) of this section for an exception.) (ii) Provide evidence that the services were furnished if the intermediary or carrier requests it. (iii) Provide evidence of payment of the bill and of the identity of the person who paid it. (2) If a person claims payment as the legal representative of the deceased beneficiary's estate, he or she must also submit a copy of the papers showing appointment as legal representative. (3) If a person claims payment as a survivor of the beneficiary, he or she must also submit evidence, if the intermediary or carrier requests it, that he or she is highest on the priority list of paragraph (c)(3) of this section. (f) Evidence of payment. Evidence of payment may be— (1) A receipted bill, or a properly completed “Report of Services” section of a claim form, showing who paid the bill; (2) A cancelled check; (3) A written statement from the provider or supplier or an authorized staff member; or (4) Other probative evidence. (g) Exception: Claim submitted before beneficiary died. If a claim and itemized bill has been submitted by or on behalf of the beneficiary before he or she died, submission of another claim form and itemized bill is not required; any written request by the person seeking payment is sufficient. (a) Scope. This section specifies whom Medicare pays, and the conditions for payment when the beneficiary has died and the bill has not been paid. (b) Situation. (1) The beneficiary has received covered Part B services furnished by a physician or other supplier. (2) The beneficiary died without making an assignment to the physician or other supplier or receiving Medicare payment. (3) The bill has not been paid. (c) To whom payment is made. In the situation described in paragraph (b) of this section, Medicare pays as follows: (1) Payment to the supplier. Medicare pays the physician or other supplier if he or she— (i) Files a claim on a CMS-prescribed form in accordance with the applicable requirements of this subpart; (ii) Upon request from the carrier, provides evidence that the services for which it claims payment were, in fact, furnished; and (iii) Agrees in writing to accept the reasonable charge as the full charge for the services. (2) Payment to a person who assumes legal obligation to pay for the services. If the physician or other supplier does not agree to accept the reasonable charge as full charge for the service, Medicare pays any person who submits to the carrier all of the following: (i) A statement indicating that he or she has assumed legal obligation to pay for the services. (ii) A claim on a CMS-prescribed form in accordance with the requirements of this subpart. (If a claim had been submitted by or on behalf of the beneficiary before he or she died, submission of another claim form is not required; a written request by the person seeking payment meets the requirement for a claim.) (iii) An itemized bill that identifies the claimant as the person to whom the physician or other supplier holds responsible for payment. (If such an itemized bill had been submitted by or on behalf of the beneficiary before he or she died, submission of another itemized bill is not required.) (iv) If the intermediary or carrier requests it, evidence that the services were actually furnished. [53 FR 6634, Mar. 2, 1988, as amended at 53 FR 28388, July 28, 1988] (a) Conditions for payment. Medicare may pay an entity for Part B services furnished by a physician or other supplier if the entity meets all of the following requirements: (1) Provides coverage of the service under a complementary health benefit plan (this is, the coverage that the plan provides is complementary to Medicare benefits and covers only the amount by which the Part B payment falls short of the approved charge for the service under the plan). (2) Has paid the person who provided the service an amount (including the amount payable under the Medicare program) that the person accepts as full payment. (3) Has the written authorization of the beneficiary (or of a person authorized to sign claims on his behalf under §424.36) to receive the Part B payment for the services for which the entity pays. (4) Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from the beneficiary, his or her survivors or estate. (5) Submits any information CMS or the carrier may request, including an itemized physician or supplier bill, in order to apply the requirements under the Medicare program. (6) Identifies and excludes from its requests for payment all services for which Medicare is the secondary payer. (b) Services paid for by the entity. An entity is not required to pay and claim reimbursement for all Part B services furnished to members of its plans. However, if it does not pay and claim reimbursement for all those services, it must establish in advance precise criteria for identifying the services for which it will pay and claim reimbursement. [53 FR 28388, July 28, 1988; 53 FR 40231, Oct. 14, 1988] (a) Statutory basis. This subpart implements sections 1815(c) and 1842(b)(6) of the Act, which establish limitations on who may receive payments due a provider or supplier of services or a beneficiary. (b) Scope. This subpart— (1) Prohibits the assignment, reassignment, or other transfer of the right to Medicare payments except under specified conditions; (2) Sets forth the sanctions that CMS may impose on a provider or supplier that violates this prohibition, or on a supplier that violates the conditions to which it agreed in accepting assignment from the individual; and (3) Specifies the conditions for payment under court-ordered assignments or reassignments. As used in this subpart, unless the context indicates otherwise— Court of competent jurisdiction means a court that has jurisdiction over the subject matter and the parties before it. Facility means a hospital or other institution that furnishes health care services to inpatients. Entity means a person, group, or facility that is enrolled in the Medicare program. Power of attorney means any written documents by which a principal authorizes an agent to— (1) Receive, in the agent's name, any payments due the principal; (2) Negotiate checks payable to the principal; or (3) Receive, in any other manner, direct payment of amounts due the principal. [53 FR 6634, Mar. 2, 1988, as amended at 69 FR 66426, Nov. 15, 2004] (a) Basic prohibition. Except as specified in paragraph (b) of this section, Medicare does not pay amounts that are due a provider to any other person under assignment, or power of attorney, or any other direct payment arrangement. (b) Exceptions to the prohibition—(1) Payment to a government agency or entity. Subject to the requirements of the Assignment of Claims Act (31 U.S.C. 3727), Medicare may pay a government agency or entity under an assignment by the provider. (2) Payment under assignment established by court order. Medicare may pay under an assignment established by, or in accordance with, the order of a court of competent jurisdiction if the assignment meets the conditions set forth in §424.90. (3) Payment to an agent. Medicare may pay an agent who furnishes billing and collection services to the provider if the following conditions are met: (i) The agent receives the payment under an agency agreement with the provider; (ii) The agent's compensation is not related in any way to the dollar amounts billed or collected; (iii) The agent's compensation is not dependent upon the actual collection of payment; (iv) The agent acts under payment disposition instructions that the provider may modify or revoke at any time; and (v) The agent, in receiving the payment, acts only on behalf of the provider. Payment to an agent will always be made in the name of the provider. CMS may terminate a provider agreement, in accordance with §489.53(a)(1) of this chapter, if the provider— (a) Executes or continues a power of attorney, or enters into or continues any other arrangement, that authorizes or permits payment contrary to the provisions of this subpart; or (b) Fails to furnish, upon request by CMS or the intermediary, evidence necessary to establish compliance with the requirements of this subpart. (a) Basic prohibition. Except as specified in paragraph (b) of this section, Medicare does not pay amounts that are due a supplier under an assignment to any other person under reassignment, power of attorney, or any other direct arrangement. Nothing in this section alters a party's obligations under the anti-kickback statute (section 1128B(b) of the Act), the physician self-referral prohibition (section 1877 of the Act), the rules regarding physician billing for purchased diagnostic tests (§414.50 of this chapter), the rules regarding payment for services and supplies incident to a physician's professional services (§410.26 of this chapter), or any other applicable Medicare laws, rules, or regulations. (b) Exceptions to the basic rule—(1) Payment to employer. Medicare may pay the supplier's employer if the supplier is required, as a condition of employment, to turn over to the employer the fees for his or her services. (2) Payment to an entity under a contractual arrangement. Medicare may pay an entity enrolled in the Medicare program if there is a contractual arrangement between the entity and the supplier under which the entity bills for the supplier's services, subject to the provisions of paragraph (d) of this section. (3) Payment to a government agency or entity. Subject to the requirements of the Assignment of Claims Act (31 U.S.C. 3727), Medicare may pay a government agency or entity under a reassignment by the supplier. (4) Payment under a reassignment established by court order. Medicare may pay under a reassignment established by, or in accordance with, the order of a court competent jurisdiction, if the reassignment meets the conditions set forth in §424.90. (5) Payment to an agent. Medicare may pay an agent who furnishes billing and collection services to the supplier, or to the employer, facility, or system specified in paragraphs (b) (1), (2) and (3) of this section, if the conditions of §424.73(b)(3) for payment to a provider's agent are met by the agent of the supplier or of the employer, facility, or system. Payment to an agent will always be made in the name of the supplier or the employer, facility, or system. (c) Rules applicable to an employer or entity. An employer or entity that may receive payment under paragraph (b)(1) or (b)(2) of this section is considered the supplier of those services for purposes of subparts C, D, and E of this part, subject to the provisions of paragraph (d) of this section. (d) Reassignment to an entity under a contractual arrangement: Conditions and limitations—(1) Liability of the parties. An entity enrolled in the Medicare program that receives payment under a contractual arrangement under paragraph (b)(2) of this section and the supplier that otherwise receives payment are jointly and severally responsible for any Medicare overpayment to that entity. (2) Access to records. The supplier furnishing the service has unrestricted access to claims submitted by an entity for services provided by that supplier. [53 FR 6634, Mar. 2, 1988, as amended at 54 FR 4027, Jan. 27, 1989; 69 FR 66426, Nov. 15, 2004; 70 FR 16722, Apr. 1, 2005] (a) Scope. This section sets forth the conditions and procedures for revocation of the right of a supplier or other party to receive Medicare payments. (b) Definition. As used in this section, other party means an employer, facility, or health care delivery system to which Medicare may make payment under §424.80(b) (1), (2), or (3). (c) Basis for revocation. CMS may revoke the right of a supplier or other party to receive Medicare payments if the supplier or other party, after warning by CMS or the carrier— (1) Violates the terms of assignment in §424.55(b). (2) Continues collection efforts or fails to refund moneys incorrectly collected, in violation of the terms of assignment in §424.55(b). (3) Executes or continues in effect a reassignment or power of attorney or any other arrangement that seeks to obtain payment contrary to the provisions of §424.80; or (4) Fails to furnish evidence necessary to establish its compliance with the requirements of §424.80. (d) Proposed revocation: Notice and opportunity for review. If CMS proposes to revoke the right to payment in accordance with paragraph (c) of this section, it will send the supplier or other party a written notice that— (1) States the reasons for the proposed revocation; and (2) Provides an opportunity for the supplier or other party to submit written argument and evidence against the proposed revocation. CMS usually allows 15 days from the date on the notice, but may extend or reduce the time as circumstances require. (e) Actual revocation: Timing, notice, and opportunity for hearing—(1) Timing. CMS determines whether to revoke after considering any written argument or evidence submitted by the supplier or other party or, if none is submitted, at the expiration of the period specified in the notice of proposed revocation. (2) Notice and opportunity for hearing. The notice of revocation specifies— (i) The reasons for the revocation; (ii) That the revocation is effective as of the date on the notice; (iii) That the supplier or other party may, within 60 days from the date on the notice (or a longer period if the notice so specifies), request an administrative hearing and may be represented by counsel or other qualified representative. (iv) That the carrier will withhold payment on any claims submitted by the supplier or other party until the period for requesting a hearing expires or, if a hearing is requested, until the hearing officer issues a decision; (v) That if the hearing decision reverses the revocation, the carrier will pay the supplier's or other party's claims; and (vi) That if a hearing is not requested or the hearing decision upholds the revocation, payment will be made to the beneficiary or to another person or agency authorized to receive payment on his or her behalf. [53 FR 6644, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988] If the supplier or other party requests a hearing under §424.82(e)(2)— (a) The hearing is conducted— (1) By a CMS hearing official who was not involved in the decision to revoke; and (2) In accordance with the procedures set forth in §§405.824 through 405.833 (but excepting §405.832(d)) and 405.860 through 405.872 of this chapter. In applying those procedures, “CMS” is substituted for “carrier”; and “hearing official”, for “hearing officer”. (b) As soon as practicable after the close of the hearing, the official who conducted it issues a hearing decision that— (1) Is based on all the evidence presented at the hearing and included in the hearing record; and (2) Contains findings of fact and a statement of reasons. (a) Basis of final determination—(1) Final determination without a hearing. If the supplier or other party does not request a hearing, CMS's revocation determination becomes final at the end of the period specified in the notice of revocation. (2) Final determination following a hearing. If there is a hearing, the hearing decision constitutes CMS's final determination. (b) Notice of final determination. CMS sends the supplier or other party a written notice of the final determination and, if there was a hearing, includes a copy of the hearing decision. (c) Application of the final determination—(1) A final determination not to revoke is the final administrative decision by CMS on the matter. (2) A final determination to revoke remains in effect until CMS finds that the reason for the revocation has been removed and that there is reasonable assurance that it will not recur. (d) Effect of revocation when supplier or other party has a financial interest in another entity. Revocation of the party's right to accept assignment also applies to any corporation, partnership, or other entity in which the party, directly or indirectly, has or acquires all or all but a nominal part of the financial interest. [53 FR 6644, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988] (a) Basic prohibition. Except as specified in paragraph (b) of this section, Medicare does not pay amounts that are due a beneficiary under §424.53 to any other person under assignment, power of attorney, or any other direct payment arrangement. (b) Exceptions—(1) Payment to a government agency or entity. Subject to the requirements of the Assignment of Claims Act (31 U.S.C. 3727), Medicare may pay a government agency or entity under an assignment by a beneficiary (or by the beneficiary's legal guardian or representative payee). (2) Payment under an assignment established by court order. Medicare may pay under an assignment established by, or in accordance with, a court order if the assignment meets the conditions set forth in §424.90. (a) Conditions for acceptance. An assignment or reassignment established by or in accordance with a court order is effective for Medicare payments only if— (1) Someone files a certified copy of the court order and of the executed assignment or reassignment (if it was necessary to execute one) with the intermediary or carrier responsible for processing the claim; and (2) The assignment or reassignment— (i) Applies to all Medicare benefits payable to a particular person or entity during a specified or indefinite time period; or (ii) Specifies a particular amount of money, payable to a particular person or entity by a particular intermediary or carrier. (b) Retention of authority to reduce interim payments to providers. A court-ordered assignment does not preclude the intermediary or carrier from reducing interim payments, as set forth in §413.64(i) of this chapter, if the provider or assignee is in imminent danger of insolvency or bankruptcy. (c) Liability of the parties. The party that receives payments under a court-ordered assignment or reassignment that meets the conditions of paragraph (a) of this section and the party that would have received payment if the court order had not been issued are jointly and severally responsible for any Medicare overpayment to the former. This subpart sets forth procedures and criteria that are followed in determining whether Medicare will pay for emergency services furnished by a hospital that is located in the United States and does not have in effect a provider agreement, that is, an agreement to participate in Medicare. As used in this subpart, unless the context indicates otherwise— Emergency services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. Hospital means a facility that— (1) Is primarily engaged in providing, by or under the supervision of doctors of medicine or osteopathy, inpatient services for the diagnosis, treatment, and care or rehabilitation of persons who are sick, injured, or disabled; (2) Is not primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care, as described in section 1861(j)(1)(A) of the Act; (3) Provides 24-hour nursing service in accordance with section 1861(e)(5) of the Act; and (4) Is licensed, or is approved as meeting the standards for licensing, by the State or local licensing agency. Reasonable charges means customary charges insofar as they are reasonable. Without additional evidence of a threat to life or health, the following situations do not in themselves indicate a need for emergency services: (a) Lack of care at home. (b) Lack of transportation to a participating hospital. (c) Death of the patient in the hospital. Medicare pays for emergency services furnished to a beneficiary by a nonparticipating hospital or under arrangements made by such a hospital if the conditions of this section are met. (a) General requirements. (1) The services are of the type that Medicare would pay for if they were furnished by a participating hospital. (2) The hospital has in effect an election to claim payment for all emergency services furnished in a calendar year in accordance with §424.104. (3) The need for emergency services arose while the beneficiary was not an inpatient in a hospital. (4) In the case of inpatient hospital services, the services are furnished during a period in which the beneficiary could not be safely discharged or transferred to a participating hospital or other institution. (5) The determination that the hospital was the most accessible hospital available and equipped to furnish the services is made in accordance with §424.106. (b) Medical information requirements. A physician (or, if appropriate, the hospital) submits medical information that— (1) Describes the nature of the emergency and specifies why it required that the beneficiary be treated in the most accessible hospital; (2) Establishes that all the conditions in paragraph (a) of this section are met; and (3) Indicates when the emergency ended, which, for inpatient hospital services, is the earliest date on which the beneficiary could be safely discharged or transferred to a participating hospital or other institution. (a) Terms of the election. The hospital agrees to the following: (1) To comply with the provisions of subpart C of part 489 of this chapter relating to charges for items and services the hospital may make to the beneficiary, or any other person on his or her behalf. (2) To comply with the provisions of subpart D of part 489 of this chapter relating to proper disposition of monies incorrectly collected from, or on behalf of a beneficiary. (3) To request payment under the Medicare program based on amounts specified in §413.74 of this chapter. (b) Filing of election statement. An election statement must be filed on a form designated by CMS, signed by an authorized official of the hospital, and either received by CMS, or postmarked, before the close of the calendar year of election. (c) Acceptance and effective date of election. If CMS accepts the election statement, the election is effective as of the earliest day of the calendar year of election from which CMS determines the hospital has been in continuous compliance with the requirements of section 1814(d) of the Act. (d) Appeal by hospital. Any hospital dissatisfied with a determination that it does not qualify to claim reimbursement shall be entitled to appeal the determination as provided in part 498 of this chapter. (e) Conditions for reinstatement after notice of failure to continue to qualify. If CMS has notified a hospital that it no longer qualifies to receive reimbursement for a calendar year, CMS will not accept another election statement from that hospital until CMS finds that— (1) The reason for its failure to qualify has been removed; and (2) There is reasonable assurance that it will not recur. (a) Basic requirement. (1) The hospital must be the most accessible one available and equipped to furnish the services. (2) CMS determines accessibility based on the factors specified in paragraphs (b) and (c) of this section and the conditions set forth in paragraph (d) of this section. (b) Factors that are considered. CMS considers the following factors in determining whether a nonparticipating hospital in a rural area meets the accessibility requirements: (1) The relative distances of participating and nonparticipating hospitals in the area. (2) The transportation facilities available to these hospitals. (3) The quality of the roads to each hospital. (4) The availability of beds at each hospital. (5) Any other factors that bear on whether or not the services could be provided sooner in the nonparticipating hospitals than in a participating hospital in the general area. In urban and suburban areas where both participating and nonparticipating hospitals are similarly available, CMS presumes that the services could have been provided in a participating hospital unless clear and convincing evidence shows that there was a medical or practical need to use the nonparticipating hospital. (c) Factors that are not considered. CMS gives no consideration to the following factors in determining whether the nonparticipating hospital was the most accessible hospital: (1) The personal preference of the beneficiary, the physician, or members of the family. (2) The fact that the attending physician did not have staff privileges in a participating hospital which was available and the most accessible to the beneficiary. (3) The location of previous medical records. (d) Conditions under which the accessibility requirement is met. If a beneficiary must be taken to a hospital immediately for required diagnosis and treatment, the nonparticipating hospital meets the accessibility requirement if— (1) It was the nearest hospital to the point where the emergency occurred, it was medically equipped to handle the type of emergency, and it was the most accessible, on the basis of the factors specified in paragraph (b) of this section; or (2) There was a closer participating hospital equipped to handle the emergency, but the participating hospital did not have a bed available or would not accept the individual. (a) Conditions for payment. Medicare pays the hospital for emergency services if the hospital— (1) Has in effect a statement of election to claim payment for all covered emergency services furnished during a calendar year, in accordance with §424.104; (2) Claims payment in accordance with §424.32; and (3) Submits evidence requested by CMS to establish that the services meet the requirements of this subpart. (b) Subsequent claims. If the hospital files subsequent claims because the initial claim did not include all the services furnished, those claims must include physicians' statements that— (1) Contain sufficient information to clearly establish that, when the additional services were furnished, the emergency still existed; and (2) Indicate when the emergency ended, which, for inpatient hospital services, is the earliest date on which the beneficiary could be safely discharged or transferred to a participating hospital or other institution. Medicare pays the beneficiary for emergency services if the following conditions are met: (a) The hospital does not have in effect an election to claim payment. (b) The beneficiary, or someone on his or her behalf, submits— (1) A claim that meets the requirements of §424.32; (2) An itemized hospital bill; and (3) Evidence requested by CMS to establish that the services meet the requirements of this subpart. This subpart sets forth the conditions for payment for services furnished in a foreign country.
Link to an amendment published at 71 FR 48143, Aug. 18, 2006. Subject to the conditions set forth in this subpart— (a) Medicare Part A pays, in the amounts specified in §413.74 of this chapter, for emergency and nonemergency inpatient hospital services furnished by a foreign hospital. (b) Medicare Part B pays for certain physicians' services and ambulance services furnished in connection with covered inpatient care in a foreign hospital, as specified in §424.124. (c) All other services furnished outside the United States are excluded from Medicare coverage, as specified in §405.313 of this chapter. Medicare Part A pays for emergency inpatient hospital services furnished by a foreign hospital if the following conditions are met: (a) At the time of the emergency that required the inpatient hospital services, the beneficiary was— (1) In the United States; or (2) In Canada traveling between Alaska and another State without unreasonable delay and by the most direct route. (b) The foreign hospital was closer to, or more accessible from, the site of the emergency than the nearest United States hospital equipped to deal with, and available to treat, the individual's illness or injury. (c) The conditions for payment for emergency services set forth in §424.103 are met. (d) The hospital is a hospital as defined in §424.101, and is licensed, or approved as meeting the conditions for licensing, by the appropriate agency of the country in which it is located. (e) The determination of whether the hospital was more accessible is made in accordance with §424.106.
Link to an amendment published at 71 FR 48143, Aug. 18, 2006. Medicare Part A pays for inpatient hospital services furnished by a foreign hospital if the following conditions are met: (a) The beneficiary is a resident of the United States. (b) The foreign hospital is closer or more accessible to the beneficiary's residence than the nearest United States hospital equipped to deal with, and available to treat, the individual's illness or injury. (c) The foreign hospital is— (1) A hospital as defined in §424.101 and, it is licensed, or approved as meeting the conditions for licensing, by the appropriate agency of the country in which it is located; and (2) Accredited by the Joint Commission on Accreditation of Hospitals (JCAH) or accredited or approved by a program of the country where it is located under standards that CMS finds to be essentially equivalent to those of the JCAH. (d) The services are covered services that Medicare would pay for if they were furnished by a participating hospital. (a) Basic rules. Medicare Part B pays for physician and ambulance services if— (1) They are furnished— (i) To an individual who is entitled to Part B benefits; and (ii) In connection with covered inpatient hospital services; and (2) They meet the conditions set forth in paragraphs (b) and (c) of this section. (b) Physician services. (1) The physician services are services covered under Medicare Part B and are furnished— (i) In the hospital, during a period of covered inpatient services; or (ii) Outside the hospital, on the day of admission and for the same condition that required inpatient admission; and (2) The physician is legally authorized to practice in the country where he or she furnishes the services. (c) Ambulance services. The ambulance services are— (1) Necessary because the use of other means of transportation is contraindicated by the beneficiary's condition; and (2) Furnished by an ambulance that meets the definition in §410.41 of this chapter. [53 FR 6646, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 64 FR 3649, Jan. 25, 1999] (a) Conditions for payment. Medicare pays the hospital if it— (1) Has in effect an election that— (i) Meets the requirements set forth in §424.104; and (ii) Reflects the hospital's intent to claim for all covered services furnished during a calendar year. (2) Claims payment in accordance with §§424.32 and 413.74 of this chapter; and (3) Submits evidence requested by CMS to establish that the services meet the requirements of this subpart. (b) Amount of payment. Payment is made (in accordance with §413.74 of this chapter) on the basis of 100 percent of the hospital's customary charges, subject to the applicable deductible and coinsurance provisions set forth elsewhere in this chapter. (a) Conditions for payment of inpatient hospital services. Medicare pays the beneficiary if— (1) The hospital does not have in effect an election to claim payment; and (2) The beneficiary, or someone on his or her behalf, submits— (i) A claim in accordance with §424.32; (ii) An itemized hospital bill; and (iii) Evidence requested by CMS to establish that the services meet the requirements of this subpart. (b) Amount payable for inpatient hospital services. The amount payable to the beneficiary is determined in accordance with §424.109(b). (c) Conditions for payment for Part B services. Medicare pays the beneficiary for physicians' services and ambulance services as specified in §424.121, if an itemized bill for the services is submitted by the beneficiary or someone on his or her behalf and the conditions of §424.126(a) (2) and (3) are met. (d) The amount payable to the beneficiary is determined in accordance with §410.152 of this chapter. (a) U.S. Government checks—(1) Responsibility. The Treasury Department is responsible for the investigation and settlement of claims in connection with Treasury checks issued on behalf of CMS. (2) Action by CMS. CMS forwards reports of lost, stolen, defaced, mutilated, destroyed, or forged Treasury checks to the Treasury Department disbursing center responsible for issuing checks. (3) Action by the Treasury Department. The Treasury Department will replace and begin reclamation of Treasury checks in accordance with Treasury Department regulations (31 CFR parts 235, 240, and 245). (b) Intermediary and carrier benefit checks. Checks issued by intermediaries and carriers are drawn on commercial banks and are not subject to the Federal laws and Treasury Department regulations that govern Treasury checks. Replacement procedures are carried out in accordance with §424.352 under applicable State law (including any Federal banking laws or regulations that may affect the relevant State proceedings). [58 FR 65129, Dec. 13, 1993] (a) When an intermediary or carrier is notified by a payee that a check has been lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsement, the intermediary or carrier contacts the commercial bank on whose paper the check was drawn and determines whether the check has been negotiated. (b) If the check has been negotiated— (1) The intermediary or carrier provides the payee with a copy of the check and other pertinent information (such as a claim form, affidavit or questionnaire to be completed by the payee) required to pursue his or her claim in accordance with State law and commercial banking regulations. (2) To pursue the claim, the payee must examine the check and certify (by completing the claim form, questionnaire or affidavit) that the endorsement is not the payee's. (3) The claim form and other pertinent information is sent to the intermediary or carrier for review and processing of the claim. (4) The intermediary or carrier reviews the payee's claim. If the intermediary or carrier determines that the claim appears to be valid, it forwards the claim and a copy of the check to the issuing bank. The intermediary or carrier takes further action to recover the proceeds of the check in accordance with the State law and regulations. (5) Once the intermediary or carrier recovers the proceeds of the initial check, the intermediary or carrier issues a replacement check to the payee. (6) If the bank of first deposit refuses to settle on the check for good cause, the payee must pursue the claim on his or her own and the intermediary or carrier will not reissue the check to the payee. (c) If the check has not been negotiated— (1) The intermediary or carrier arranges with the bank to stop payment on the check; and (2) Except as provided in paragraph (d), the intermediary or carrier reissues the check to the payee. (d) No check may be reissued under (c)(2) unless the claim for a replacement check is received by the intermediary or carrier no later than 1 year from the date of issuance of the original check, unless State law (including any applicable Federal banking laws or regulations that may affect the relevant State proceeding) provides a longer period which will control. [58 FR 65130, Dec. 13, 1993] Source: 71 FR 20776, Apr. 21, 2006, unless otherwise noted.
The provisions of this subpart contain the requirements for enrollment, periodic resubmission and certification of enrollment information for revalidation, and timely reporting of updates and changes to enrollment information. These requirements apply to all providers and suppliers except for physicians and practitioners who have entered into a private contract with a beneficiary as described in part 405, subpart D of this chapter. Providers and suppliers must meet and maintain these enrollment requirements to bill either the Medicare program or its beneficiaries for Medicare covered services or supplies. As used in this subpart, unless the context indicates otherwise— Approve/Approval means the enrolling provider or supplier has been determined to be eligible under Medicare rules and regulations to receive a Medicare billing number and be granted Medicare billing privileges. Authorized official means an appointed official (for example, chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program. Deactivate means that the provider or supplier's billing privileges were stopped, but can be restored upon the submission of updated information. Delegated official means an individual who is delegated by the “Authorized Official,” the authority to report changes and updates to the enrollment record. The delegated official must be an individual with ownership or control interest in, or be a W–2 managing employee of the provider or supplier. Deny/Denial means the enrolling provider or supplier has been determined to be ineligible to receive Medicare billing privileges for Medicare covered items or services provided to Medicare beneficiaries. Enroll/Enrollment means the process that Medicare uses to establish eligibility to submit claims for Medicare covered services and supplies. The process includes— (1) Identification of a provider or supplier; (2) Validation of the provider's or supplier's eligibility to provide items or services to Medicare beneficiaries; (3) Identification and confirmation of the provider or supplier's practice location(s) and owner(s); and (4) Granting the provider or supplier Medicare billing privileges. Enrollment application means a CMS-approved paper enrollment application or an electronic Medicare enrollment process approved by OMB. Managing employee means a general manager, business manager, administrator, director, or other individual that exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operation of the provider or supplier, either under contract or through some other arrangement, whether or not the individual is a W–2 employee of the provider or supplier. Operational means the provider or supplier has a qualified physical practice location, is open to the public for the purpose of providing health care related services, is prepared to submit valid Medicare claims, and is properly staffed, equipped, and stocked (as applicable, based on the type of facility or organization, provider or supplier specialty, or the services or items being rendered), to furnish these items or services. Owner means any individual or entity that has any partnership interest in, or that has 5 percent or more direct or indirect ownership of the provider or supplier as defined in sections 1124 and 1124A(A) of the Act. Reject/Rejected means that the provider or supplier's enrollment application was not processed due to incomplete information, or that additional information or corrected information was not received from the provider or supplier in a timely manner. Revoke/Revocation means that the provider or supplier's billing privileges are terminated. To receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. Once enrolled, the provider or supplier receives billing privileges and is issued a valid billing number effective for the date a claim was submitted for an item that was furnished or a service that was rendered. (See 45 CFR Part 162 for information on the National Provider Identifier and its use as the Medicare billing number.) (a) Providers and suppliers must submit enrollment information on the applicable enrollment application. Once the provider or supplier successfully completes the enrollment process, including, if applicable, a State survey and certification or accreditation process, CMS enrolls the provider or supplier into the Medicare program. To be enrolled, a provider or supplier must meet enrollment requirements specified in paragraph (c) of this section. (b) The effective dates for reimbursement are specified in §489.13 of this chapter for providers and suppliers requiring State survey or certification or accreditation, §424.5 and §424.44 for non-surveyed or certified/accredited suppliers, and §424.57 and section 1834(j)(1)(A) of the Act for DMEPOS suppliers. (c) The effective date for reimbursement for providers and suppliers seeking accreditation from a CMS-approved accreditation organization as specified in §489.13(d). (d) Providers and suppliers must meet the following enrollment requirements: (1) Submittal of the enrollment application. A provider or supplier must submit a complete enrollment application and supporting documentation to the designated Medicare fee-for-service contractor. (2) Content of the enrollment application. Each submitted enrollment application must include the following: (i) Complete, accurate, and truthful responses to all information requested within each section as applicable to the provider or supplier type. (ii) Submission of all documentation required by CMS under this or other statutory or regulatory authority, or under the Paperwork Reduction Act of 1995, to uniquely identify the provider or supplier. This documentation may include, but is not limited to, proof of the legal business name, practice location, social security number (SSN), tax identification number (TIN), National Provider Identifier (NPI), if issued, and owners of the business. (iii) Submission of all documentation, including all applicable Federal and State licensure and regulatory requirements that apply to the specific provider or supplier type that relate to providing health care services, required by CMS under this or other statutory or regulatory authority, or under the Paperwork Reduction Act of 1995, to establish the provider or supplier's eligibility to furnish Medicare covered items or services to beneficiaries in the Medicare program. (3) Signature(s) required on the enrollment application. The certification statement found on the enrollment application must be signed by an individual who has the authority to bind the provider or supplier, both legally and financially, to the requirements set forth in this chapter. This person must also have an ownership or control interest in the provider or supplier, as that term is defined in section 1124(a)(3) of the Act, such as, the general partner, chairman of the board, chief financial officer, chief executive officer, president, or hold a position of similar status and authority within the provider or supplier organization. The signature attests that the information submitted is accurate and that the provider or supplier is aware of, and abides by, all applicable statutes, regulations, and program instructions. (i) Requirements. The signature requirements specified in paragraphs (d)(3)(i)(A) through (C) of this section outline who must sign the enrollment application for an enrolling provider or supplier. In the case of— (A) An individual practitioner, the applying practitioner. (B) A sole proprietorship, the applying sole proprietor. (C) A corporation, partnership, group, limited liability company, or other organization (hereafter referred to collectively in this section as an organization), an authorized official, as defined in §424.502. When an authorized official signs the certification statement on behalf of an organization, the signed statement is considered legally binding upon the organization. (ii) Delegation of authority. The original enrollment application submitted for an organization's initial enrollment and all subsequent enrollment applications submitted for periodic revalidation of the organization's enrollment data (as required to maintain enrollment in the Medicare program) must be signed by an authorized official. Any updates or changes reported outside of the initial enrollment or periodic revalidation process may be signed by a delegated official(s) of the organization. The delegated official's signature binds the organization both legally and financially, as if the signature was that of the authorized official. Before the delegation of authority is established, the only acceptable signature on the enrollment application to report updates or changes to the enrollment information is that of the authorized official currently on file with Medicare. Once the delegation of authority is established, the only acceptable signatures on correspondence to report updates or changes to the enrollment information are those of the authorized official and the person(s) to whom this authority is delegated in accordance with the requirements described in this section. Individual practitioners and sole proprietors cannot delegate signature authority when submitting an enrollment application for any reason. All enrollment applications submitted by individual practitioners and sole proprietors must be signed by the enrolling or enrolled individual. Each delegation of authority to a delegated official must— (A) Be assigned by the authorized official currently on file with CMS; (B) Be submitted to CMS using the appropriate enrollment application or CMS established electronic enrollment process; (C) Include the title and SSN of each person delegated authority to update or change the organization's enrollment information; (D) Be an individual that has an ownership or control interest in the organization or is a W–2 managing employee as defined in section 1126(b) of the Act; and (E) Be signed by the authorized official and the delegated official(s) of the organization. (4) Verification of information. The information submitted by the provider or supplier on the applicable enrollment application must be such that CMS can validate it for accuracy at the time of submission. (5) Completion of any applicable State surveys, certifications, and provider agreements. The providers or suppliers who are mandated under the provision in part 488 of this chapter to be surveyed or certified by the State survey and certification agency, and to also enter into and sign a provider agreement as outlined in part 489 of this chapter, must also meet those requirements as part of the process to obtain Medicare billing privileges. (6) Ability to furnish Medicare covered items or services. The provider or supplier must be operational to furnish Medicare covered items or services before being granted Medicare billing privileges. (7) Additional requirements. Providers and suppliers must meet the provisions of §424.520 regarding additional compliance and reporting requirements. (8) On-site review. CMS reserves the right, when deemed necessary, to perform on-site inspections of a provider or supplier to verify that the enrollment information submitted to CMS or its agents is accurate and to determine compliance with Medicare enrollment requirements. Site visits for enrollment purposes do not affect those site visits performed for establishing compliance with conditions of participation. (i) Medicare Part A providers. CMS determines, upon on-site review, that the provider is no longer operational to furnish Medicare covered items or services, or the provider fails to satisfy any of the Medicare enrollment requirements. (ii) Medicare Part B suppliers. CMS determines, upon review that the supplier is no longer operational to furnish Medicare covered items or services, or the supplier has failed to satisfy any or all of the Medicare enrollment requirements, or has failed to furnish Medicare covered items or services as required by the statute or regulations. To maintain Medicare billing privileges, a provider or supplier (other than a DMEPOS supplier) must resubmit and recertify the accuracy of its enrollment information every 5 years. All providers and suppliers currently billing the Medicare program or initially enrolling in the Medicare program are required to complete the applicable enrollment application. The provider or supplier then enters a 5-year revalidation cycle once a completed enrollment application is submitted and validated. (Ambulance service providers must continue to resubmit enrollment information in accordance with §410.41(c)(2) of this chapter and DMEPOS suppliers must continue to renew enrollment in accordance with §424.57(e)). The requirements for the resubmission, recertification and reverification of enrollment information include the following: (a) Submission of the enrollment application and supporting documentation. The provider or supplier must meet the submission, content, signature, verification, operational, inspection, and other requirements outlined in §424.510. (1) CMS contacts each provider or supplier directly when it is time to revalidate their enrollment information. (2) A provider or supplier must submit to CMS the applicable enrollment application with complete and accurate information and applicable supporting documentation within 60 calendar days of our notification to resubmit and certify to the accuracy of its enrollment information. (b) Completion of any applicable State surveys, certifications and provider agreements. A new certification and a new provider agreement are not required for the purpose of resubmission and certification for revalidation of enrollment information. Providers and suppliers must continue to meet the requirements of parts 488 and 489 of this chapter, or any currently established supplier agreement, if applicable. (c) On-site inspections. CMS reserves the right to perform on-site inspections of a provider or supplier to verify that the information submitted to CMS or its agents is accurate and to determine compliance with Medicare enrollment requirements. Site visits for enrollment purposes do not affect those site visits performed for establishing compliance with conditions of participation. (1) Medicare Part A providers. CMS determines, upon on-site review, that the provider is no longer operational to furnish Medicare covered items or services, or the provider fails to satisfy any of the Medicare enrollment requirements. (2) Medicare Part B suppliers. CMS determines, upon review that the supplier is no longer operational to furnish Medicare covered items or services, or the supplier has failed to satisfy any or all of the Medicare enrollment requirements, or has failed to furnish Medicare covered items or services as required by the statute or regulations. (d) Off Cycle revalidations. (1) CMS reserves the right to perform off cycle revalidations in addition to the regular 5-year revalidations and may request that a provider or supplier recertify the accuracy of the enrollment information when warranted to assess and confirm the validity of the enrollment information maintained by CMS. Off cycle revalidations may be triggered as a result of random checks, information indicating local health care fraud problems, national initiatives, complaints, or other reasons that cause CMS to question the compliance of the provider or supplier with Medicare enrollment requirements. Off cycle revalidations may be accompanied by site visits. (2) CMS reserve the right to adjust the routine 5-year revalidation schedule if we determine that revalidation should occur on a more frequent basis due to complaints or evidence we receive indicating noncompliance with the statute or regulations by specific provider or supplier types. The schedule may also be on a less frequent basis if we determine that the integrity of and compliance with the statute and regulations by specific provider or supplier types indicates that less frequent validation is justified. If a change occurs, CMS notifies all affected providers and suppliers at least 90 days in advance of implementing the change. (3) CMS revalidates enrollment information for ambulance service suppliers in accordance with §410.41(c)(2) of this chapter (Requirements for ambulance suppliers), and DMEPOS suppliers renews enrollment in accordance with §424.57(e) (Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing numbers). (a) Certifying compliance. CMS enrolls and maintains an active enrollment status for a provider or supplier when that provider or supplier certifies that it meets, and continues to meet, and CMS verifies that it meets, and continues to meet, all of the following requirements: (1) Compliance with title XVIII of the Act and applicable Medicare regulations. (2) Compliance with Federal and State licensure, certification and regulatory requirements, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare. (3) Not employing or contracting with individuals or entities— (i) Excluded from participation in any Federal health care programs, for the provision of items and services covered under the programs, in violation of section 1128A (a)(6) of the Act; or (ii) Debarred by the General Services Administration (GSA) from any other Executive Branch procurement or nonprocurement programs or activities, in accordance with the Federal Acquisition and Streamlining Act of 1994, and with the HHS Common Rule at 45 CFR part 76. (b) Reporting requirements. Following enrollment, a provider or supplier must report to CMS any changes to the information furnished on the enrollment application and furnish supporting documentation within 90 calendar days of the change, with the exception of DMEPOS suppliers which are required to report changes of information within 30 days as specified in §424.57(c)(2), or a change of ownership or control of the provider or supplier that must also be reported within 30 calendar days. Failure to do so may result in the deactivation or revocation of the provider or supplier's Medicare billing privileges. (a) Reasons for rejection. CMS may reject a provider or supplier's enrollment application for the following reasons: (1) The provider or supplier fails to furnish complete information on the provider/supplier enrollment application within 60 calendar days from the date of the contractor request for the missing information. (2) The provider or supplier fails to furnish all required supporting documentation within 60 calendar days of submitting the enrollment application. (b) Extension of 60-day period. CMS, at its discretion, may choose to extend the 60-day period if CMS determines that the provider or supplier is actively working with CMS to resolve any outstanding issues. (c) Resubmission after rejection. To enroll in Medicare and obtain Medicare billing privileges after notification of a rejected enrollment application, the provider or supplier must complete and submit a new enrollment application and submit all supporting documentation for CMS review and approval. (d) Additional review. Enrollment applications that are rejected are not afforded appeal rights. (a) Reasons for denial. CMS may deny a provider's or supplier's enrollment in the Medicare program for the following reasons: (1) Compliance. The provider or supplier at any time is found not to be in compliance with the Medicare enrollment requirements described in this section or on the applicable enrollment application to the type of provider or supplier enrolling, and has not submitted a plan of corrective action as outlined in part 488 of this chapter. (2) Provider or supplier conduct. A provider, supplier, an owner, managing employee, an authorized or delegated official, medical director, supervising physician, or other health care personnel furnishing Medicare reimbursable services who is required to be reported on the enrollment application, in accordance with section 1862(e)(1) of the Act, is— (i) Excluded from the Medicare, Medicaid and any other Federal health care programs, as defined in §1001.2 of this chapter, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of the Act. (ii) Debarred, suspended, or otherwise excluded from participating in any other Federal procurement or nonprocurement activity in accordance with section 2455 of the Federal Acquisition Streamlining Act (FASA). (3) Felonies. If within the 10 years preceding enrollment or revalidation of enrollment, the provider, supplier, or any owner of the provider or supplier, was convicted of a Federal or State felony offense that CMS has determined to be detrimental to the best interests of the program and its beneficiaries. CMS considers the severity of the underlying offense. (i) Offenses include—(A) Felony crimes against persons, such as murder, rape, or assault, and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. (B) Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. (C) Any felony that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit that results in a conviction of criminal neglect or misconduct). (D) Any felonies outlined in section 1128 of the Act. (ii) Denials based on felony convictions are for a period to be determined by the Secretary, but not less than 10 years from the date of conviction if the individual has been convicted on one previous occasion for one or more offenses. (4) False or misleading information. The provider or supplier has submitted false or misleading information on the enrollment application to gain enrollment in the Medicare program. (Offenders may be referred to the Office of Inspector General for investigation and possible criminal, civil, or administrative sanctions.) (5) On-site review. Upon on-site review or other reliable evidence, we determine that the provider or supplier is not operational, or is not meeting Medicare enrollment requirements to furnish Medicare covered items or services. Upon on-site review, CMS determines that— (i) A Medicare Part A provider is no longer operational to furnish Medicare covered items or services, or the provider fails to satisfy any of the Medicare enrollment requirements. (ii) A Medicare Part B supplier is no longer operational to furnish Medicare covered items or services, or the supplier has failed to satisfy any or all of the Medicare enrollment requirements, or has failed to furnish Medicare covered items or services as required by the statute or regulations. (b) Resubmission after denial. A provider or supplier that is denied enrollment in the Medicare program cannot submit a new enrollment application until the following has occurred if the denial: (1) Was not appealed, the provider or supplier may reapply after its appeal rights have lapsed. (2) Was appealed, the provider or supplier may reapply after notification that the determination was upheld. (c) Reversal of denial. If the denial was due to adverse activity (sanction, exclusion, debt, felony) of an owner, managing employee, an authorized or delegated official, medical director, supervising physician, or other health care personnel of the provider or supplier furnishing Medicare reimbursable services, the denial may be reversed if the provider or supplier terminates and submits proof that it has terminated its business relationship with that individual or organization within 30 days of the denial notification. (d) Additional review. When a provider or supplier is denied enrollment in Medicare, CMS automatically reviews all other related Medicare enrollment files that the denied provider or supplier has an association with (for example, as an owner or managing employee) to determine if the denial warrants an adverse action of the associated Medicare provider or supplier. (e) Effective date of denial. Denial becomes effective within 30 days of the initial denial notification. (a) Reasons for revocation. CMS may revoke a currently enrolled provider or supplier's Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons: (1) Noncompliance. The provider or supplier is determined not to be in compliance with the enrollment requirements described in this section or in the enrollment application applicable for its provider or supplier type and has not submitted a plan of corrective action as outlined in part 488 of this chapter. All providers and suppliers are granted an opportunity to correct the deficient compliance requirement prior to a final determination to revoke billing privileges. (i) CMS may request additional documentation from the provider or supplier to determine compliance if adverse information is received or otherwise found concerning the provider or supplier. (ii) Requested additional documentation must be submitted within 60 calendar days of request. (2) Provider or supplier conduct. The provider or supplier, or any owner, managing employee, authorized or delegated official, medical director, supervising physician, or other health care personnel of the provider or supplier is— (i) Excluded from the Medicare, Medicaid, and any other Federal health care program, as defined in §1001.2 of this chapter, in accordance with section 1128, 1128A, 1156, 1842, 1862, 1867 or 1892 of the Act. (ii) Is debarred, suspended, or otherwise excluded from participating in any other Federal procurement or nonprocurement program or activity in accordance with the FASA implementing regulations and the Department of Health and Human Services nonprocurement common rule at 45 CFR part 76. (3) Felonies. The provider, supplier, or any owner of the provider or supplier, within the 10 years preceding enrollment or revalidation of enrollment, was convicted of a Federal or State felony offense that CMS has determined to be detrimental to the best interests of the program and its beneficiaries. (i) Offenses include— (A) Felony crimes against persons, such as murder, rape, assault, and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. (B) Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions. (C) Any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that results in a conviction of criminal neglect or misconduct. (D) Any felonies that would result in mandatory exclusion under section 1128(a) of the Act. (ii) Denials based on felony convictions are for a period to be determined by the Secretary, but not less than 10 years from the date of conviction if the individual has been convicted on one previous occasion for one or more offenses. (4) False or misleading information. The provider or supplier certified as “true” misleading or false information on the enrollment application to be enrolled or maintain enrollment in the Medicare program. (Offenders may be subject to either fines or imprisonment, or both, in accordance with current law and regulations.) (5) On-site review. CMS determines, upon on-site review, that the provider or supplier is no longer operational to furnish Medicare covered items or services, or is not meeting Medicare enrollment requirements under statute or regulation to supervise treatment of, or to provide Medicare covered items or services for, Medicare patients. Upon on-site review, CMS determines that— (i) A Medicare Part A provider is no longer operational to furnish Medicare covered items or services, or the provider fails to satisfy any of the Medicare enrollment requirements. (ii) A Medicare Part B supplier is no longer operational to furnish Medicare covered items or services, or the supplier has failed to satisfy any or all of the Medicare enrollment requirements, or has failed to furnish Medicare covered items or services as required by the statute or regulations. (6) Inadequate reverification information. The provider or supplier fails to furnish complete and accurate information and all supporting documentation within 60 calendar days of the provider or supplier's notification from CMS to submit an enrollment application and supporting documentation, or resubmit and certify to the accuracy of its enrollment information. (7) Misuse of billing number. The provider or supplier knowingly sells to or allows another individual or entity to use its billing number. This does not include those providers or suppliers who enter into a valid reassignment of benefits as specified in §424.80 or a change of ownership as outlined in §489.18 of this chapter. (b) Effect of revocation on provider agreements. When a provider's or supplier's billing privilege is revoked, any provider agreement in effect at the time of revocation is terminated effective with the date of revocation. (c) Re-enrollment after revocation. If a provider or supplier seeks to re-establish enrollment in the Medicare program after notification that its billing privileges is revoked (either after the appeals process is exhausted or in place of the appeals process), the following conditions apply: (1) The provider or supplier must re-enroll in the Medicare program through the completion and submission of a new applicable enrollment application and applicable documentation, as a new provider or supplier, for validation by CMS. (2) Providers must be resurveyed and recertified by the State survey agency as a new provider and must establish a new provider agreement with CMS's Regional Office. (d) Reversal of revocation. If the revocation was due to adverse activity (sanction, exclusion, or felony) against an owner, managing employee, or an authorized or delegated official; or a medical director, supervising physician, or other personnel of the provider or supplier furnishing Medicare reimbursable services, the revocation may be reversed if the provider or supplier terminates and submits proof that it has terminated its business relationship with that individual within 30 days of the revocation notification. (e) Additional review. When a provider or supplier is revoked from the Medicare program, CMS automatically reviews all other related Medicare enrollment files that the revoked provider or supplier has an association with (for example, as an owner or managing employee) to determine if the revocation warrants an adverse action of the associated Medicare provider or supplier. (f) Effective date of revocation. Revocation becomes effective within 30 days of the initial revocation notification. (a) Reasons for deactivation. CMS may deactivate a provider or supplier's Medicare billing privileges for the following reasons: (1) The provider or supplier does not submit any Medicare claims for 12 consecutive calendar months. The 12 month period will begin the 1st day of the 1st month without a claims submission through the last day of the 12th month without a submitted claim. (2) The provider or supplier does not report a change to the information supplied on the enrollment application within 90 calendar days of when the change occurred. Changes that must be reported include, but are not limited to, a change in practice location, a change of any managing employee, and a change in billing services. A change in ownership or control must be reported within 30 calendar days as specified in §424.520(b) and §424.550(b). (b) Reactivation of billing privileges. (1) When deactivated for any reason other than nonsubmission of a claim, the provider or supplier must complete and submit a new enrollment application to reactivate its Medicare billing privileges or, when deemed appropriate, at a minimum, recertify that the enrollment information currently on file with Medicare is correct. (2) Providers and suppliers deactivated for nonsubmission of a claim are required to recertify that the enrollment information currently on file with Medicare is correct and furnish any missing information as appropriate. The provider or supplier must meet all current Medicare requirements in place at the time of reactivation, and be prepared to submit a valid Medicare claim. (3) Reactivation of Medicare billing privileges does not require a new certification of the provider or supplier by the State survey agency or the establishment of a new provider agreement. (c) Effect of deactivation. Deactivation of Medicare billing privileges is considered an action to protect the provider or supplier from misuse of its billing number and to protect the Medicare Trust Funds from unnecessary overpayments. The deactivation of Medicare billing privileges does not have any effect on a provider or supplier's participation agreement or any conditions of participation. (a) A provider or supplier that is denied enrollment in the Medicare program or whose Medicare enrollment has been revoked may appeal CMS' decision in accordance with part 405, subpart H, for suppliers, or part 498, subpart A for providers, of this chapter, which set forth the appeals process for providers and suppliers. When revocation of billing privileges also results in the termination of a corresponding provider agreement, the provider may appeal CMS' decision in accordance with part 498 of this chapter with the final decision of the appeal applying to both the billing privileges and the provider agreement. Payment is not made during the appeals process. If the provider or supplier is successful in overturning a denial or revocation, unpaid claims for services furnished during the overturned period may be resubmitted. (b) A provider or supplier whose billing privileges are deactivated may file a rebuttal in accordance with §405.374 of this chapter. (c) The provider or supplier must be able to demonstrate that it meets the enrollment requirements and it must be able to make available any documents and records that support the provisions of this regulation and the Medicare enrollment application if requested by CMS or its agents. (a) General rule. A provider or supplier is prohibited from selling its Medicare billing number or privileges to any individual or entity, or allowing another individual or entity to use its Medicare billing number. (b) Change of ownership. In the case of a provider undergoing a change of ownership in accordance with part 489, subpart A of this chapter, the current owner and the prospective new owner must complete and submit enrollment applications before completion of the change of ownership. If the current owner fails to complete and submit an enrollment application to report the change, the current owner may be sanctioned or penalized, even after the date of ownership change, in accordance with §424.520, §424.540, and §489.53 of this chapter. If the prospective new owner fails to submit a new enrollment application containing information concerning the new owner within 30 days of the change of ownership, CMS may deactivate the Medicare billing number. If an incomplete enrollment application is submitted, CMS may also deactivate the Medicare billing number based upon material omissions on the submitted enrollment application, or based on preliminary information received or determined by CMS that makes CMS question whether the new owner is ultimately granted a final transference of the provider agreement. (c) Suppliers not covered by part 489 of this chapter. For those suppliers not covered by part 489 of this chapter, any change in the ownership or control of that supplier must be reported on the enrollment application within 30 days of the change as noted in §424.540(a)(2). Generally, a change of ownership that also changes the tax identification number requires the completion and submission of a new enrollment application from the new owner. (a) No payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary by suppliers of durable medical equipment, prosthetics, orthotics, and other supplies unless the supplier obtains (and renews, as set forth in section 1834(j) of the Act) Medicare billing privileges. (b) No payment may be made for otherwise Medicare covered items or services furnished to a Medicare beneficiary by a provider or supplier if the billing privileges of the provider or supplier are deactivated, denied, or revoked. The Medicare beneficiary has no financial responsibility for expenses, and the provider or supplier must refund on a timely basis to the Medicare beneficiary any amounts collected from the Medicare beneficiary for these otherwise Medicare covered items or services. (c) If any provider or supplier furnishes an otherwise Medicare covered item or service for which payment may not be made by reason of paragraph (b) of this section, any expense incurred for such otherwise Medicare covered item or service shall be the responsibility of the provider or supplier. The provider or supplier may also be criminally liable for pursuing payments that may not be made by reason of paragraph (b) of this section, in accordance with section 1128B(a)(3) of the Act.
Title 42: Public Health
PART 424—CONDITIONS FOR MEDICARE PAYMENT
Section Contents
§ 424.1 Basis and scope.
§ 424.3 Definitions.
§ 424.5 Basic conditions.
§ 424.7 General limitations.
§ 424.10 Purpose and scope.
§ 424.11 General procedures.
§ 424.13 Requirements for inpatient services of hospitals other than psychiatric hospitals.
§ 424.14 Requirements for inpatient services of inpatient psychiatric facilities.
§ 424.15 Requirements for inpatient CAH services.
§ 424.16 Timing of certification for individual admitted to a hospital before entitlement to Medicare benefits.
§ 424.20 Requirements for posthospital SNF care.
§ 424.22 Requirements for home health services.
§ 424.24 Requirements for medical and other health services furnished by providers under Medicare Part B.
§ 424.27 Requirements for comprehensive outpatient rehabilitation facility (CORF) services.
§ 424.30 Scope.
§ 424.32 Basic requirements for all claims.
§ 424.33 Additional requirements: Claims for services of providers and claims by suppliers and nonparticipating hospitals.
§ 424.34 Additional requirements: Beneficiary's claim for direct payment.
§ 424.36 Signature requirements.
§ 424.37 Evidence of authority to sign on behalf of the beneficiary.
§ 424.40 Request for payment effective for more than one claim.
§ 424.44 Time limits for filing claims.
§ 424.50 Scope.
§ 424.51 Payment to the provider.
§ 424.52 Payment to a nonparticipating hospital.
§ 424.53 Payment to the beneficiary.
§ 424.54 Payment to the beneficiary's legal guardian or representative payee.
§ 424.55 Payment to the supplier.
§ 424.56 Payment to a beneficiary and to a supplier.
§ 424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.
§ 424.58 xxx
§ 424.60 Scope.
§ 424.62 Payment after beneficiary's death: Bill has been paid.
§ 424.64 Payment after beneficiary's death: Bill has not been paid.
§ 424.66 Payment to entities that provide coverage complementary to Medicare Part B.
§ 424.70 Basis and scope.
§ 424.71 Definitions.
§ 424.73 Prohibition of assignment of claims by providers.
§ 424.74 Termination of provider agreement.
§ 424.80 Prohibition of reassignment of claims by suppliers.
§ 424.82 Revocation of right to receive assigned benefits.
§ 424.83 Hearings on revocation of right to receive assigned benefits.
§ 424.84 Final determination on revocation of right to receive assigned benefits.
§ 424.86 Prohibition of assignment of claims by beneficiaries.
§ 424.90 Court ordered assignments: Conditions and limitations.
§ 424.100 Scope.
§ 424.101 Definitions.
§ 424.102 Situations that do not constitute an emergency.
§ 424.103 Conditions for payment for emergency services.
§ 424.104 Election to claim payment for emergency services furnished during a calendar year.
§ 424.106 Criteria for determining whether the hospital was the most accessible.
§ 424.108 Payment to a hospital.
§ 424.109 Payment to the beneficiary.
§ 424.120 Scope.
§ 424.121 Scope of payments.
§ 424.122 Conditions for payment for emergency inpatient hospital services.
§ 424.123 Conditions for payment for nonemergency inpatient services furnished by a hospital closer to the individual's residence.
§ 424.124 Conditions for payment for physician services and ambulance services.
§ 424.126 Payment to the hospital.
§ 424.127 Payment to the beneficiary.
§ 424.350 Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.
§ 424.352 Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements.
§ 424.500 Scope.
§ 424.502 Definitions.
§ 424.505 Basic enrollment requirement.
§ 424.510 Requirements for enrolling in the Medicare program.
§ 424.515 Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.
§ 424.520 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
§ 424.525 Rejection of a provider or supplier's enrollment application for Medicare enrollment.
§ 424.530 Denial of enrollment.
§ 424.535 Revocation of enrollment and billing privileges in the Medicare program.
§ 424.540 Deactivation of Medicare billing privileges.
§ 424.545 Provider and supplier appeal rights.
§ 424.550 Prohibitions on the sale or transfer of billing privileges.
§ 424.555 Payment liability.
Subpart A—General Provisions
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§ 424.1 Basis and scope.
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§ 424.3 Definitions.
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§ 424.5 Basic conditions.
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§ 424.7 General limitations.
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Subpart B—Certification and Plan of Treatment Requirements
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§ 424.10 Purpose and scope.
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§ 424.11 General procedures.
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§ 424.13 Requirements for inpatient services of hospitals other than psychiatric hospitals.
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§ 424.14 Requirements for inpatient services of inpatient psychiatric facilities.
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§ 424.15 Requirements for inpatient CAH services.
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§ 424.16 Timing of certification for individual admitted to a hospital before entitlement to Medicare benefits.
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§ 424.20 Requirements for posthospital SNF care.
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§ 424.22 Requirements for home health services.
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§ 424.24 Requirements for medical and other health services furnished by providers under Medicare Part B.
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§ 424.27 Requirements for comprehensive outpatient rehabilitation facility (CORF) services.
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Subpart C—Claims for Payment
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§ 424.30 Scope.
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§ 424.32 Basic requirements for all claims.
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§ 424.33 Additional requirements: Claims for services of providers and claims by suppliers and nonparticipating hospitals.
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§ 424.34 Additional requirements: Beneficiary's claim for direct payment.
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§ 424.36 Signature requirements.
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§ 424.37 Evidence of authority to sign on behalf of the beneficiary.
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§ 424.40 Request for payment effective for more than one claim.
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§ 424.44 Time limits for filing claims.
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Subpart D—To Whom Payment Is Ordinarily Made
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§ 424.50 Scope.
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§ 424.51 Payment to the provider.
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§ 424.52 Payment to a nonparticipating hospital.
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§ 424.53 Payment to the beneficiary.
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§ 424.54 Payment to the beneficiary's legal guardian or representative payee.
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§ 424.55 Payment to the supplier.
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§ 424.56 Payment to a beneficiary and to a supplier.
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§ 424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.
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§ 424.58 xxx
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Subpart E—To Whom Payment is Made in Special Situations
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§ 424.60 Scope.
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§ 424.62 Payment after beneficiary's death: Bill has been paid.
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§ 424.64 Payment after beneficiary's death: Bill has not been paid.
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§ 424.66 Payment to entities that provide coverage complementary to Medicare Part B.
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Subpart F—Limitations on Assignment and Reassignment of Claims
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§ 424.70 Basis and scope.
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§ 424.71 Definitions.
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§ 424.73 Prohibition of assignment of claims by providers.
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§ 424.74 Termination of provider agreement.
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§ 424.80 Prohibition of reassignment of claims by suppliers.
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§ 424.82 Revocation of right to receive assigned benefits.
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§ 424.83 Hearings on revocation of right to receive assigned benefits.
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§ 424.84 Final determination on revocation of right to receive assigned benefits.
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§ 424.86 Prohibition of assignment of claims by beneficiaries.
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§ 424.90 Court ordered assignments: Conditions and limitations.
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Subpart G—Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital
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§ 424.100 Scope.
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§ 424.101 Definitions.
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§ 424.102 Situations that do not constitute an emergency.
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§ 424.103 Conditions for payment for emergency services.
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§ 424.104 Election to claim payment for emergency services furnished during a calendar year.
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§ 424.106 Criteria for determining whether the hospital was the most accessible.
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§ 424.108 Payment to a hospital.
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§ 424.109 Payment to the beneficiary.
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Subpart H—Special Conditions: Services Furnished in a Foreign Country
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§ 424.120 Scope.
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§ 424.121 Scope of payments.
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§ 424.122 Conditions for payment for emergency inpatient hospital services.
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§ 424.123 Conditions for payment for nonemergency inpatient services furnished by a hospital closer to the individual's residence.
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§ 424.124 Conditions for payment for physician services and ambulance services.
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§ 424.126 Payment to the hospital.
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§ 424.127 Payment to the beneficiary.
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Subparts I–L [Reserved]
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Subpart M—Replacement and Reclamation of Medicare Payments
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§ 424.350 Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.
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§ 424.352 Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements.
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Subparts N–O [Reserved]
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Subpart P—Requirements for Establishing and Maintaining Medicare Billing Privileges
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§ 424.500 Scope.
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§ 424.502 Definitions.
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§ 424.505 Basic enrollment requirement.
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§ 424.510 Requirements for enrolling in the Medicare program.
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§ 424.515 Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.
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§ 424.520 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
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§ 424.525 Rejection of a provider or supplier's enrollment application for Medicare enrollment.
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§ 424.530 Denial of enrollment.
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§ 424.535 Revocation of enrollment and billing privileges in the Medicare program.
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§ 424.540 Deactivation of Medicare billing privileges.
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§ 424.545 Provider and supplier appeal rights.
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§ 424.550 Prohibitions on the sale or transfer of billing privileges.
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§ 424.555 Payment liability.
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