Conditions for Medicare Payment

Basis and scope.

This provision outlines the statutory basis and scope for Medicare payment conditions, including physician certification, claims filing, and payment assignment.

Purpose and scope.

This provision establishes the requirement that a physician must certify the necessity of services as a condition for Medicare payment.

Scope.

This provision defines the scope for determining Medicare payment eligibility for emergency services provided by hospitals without a Medicare provider agreement.

Definitions.

This provision defines key terms such as emergency services and hospital for the purpose of determining Medicare payment eligibility for nonparticipating facilities.

Situations that do not constitute an emergency.

This provision clarifies specific situations that do not qualify as emergencies for the purpose of Medicare payment for nonparticipating hospitals.

Conditions for payment for emergency services.

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.

Election to claim payment for emergency services furnished during a calendar year.

This provision outlines the requirements and procedures for a nonparticipating hospital to elect to claim Medicare payment for emergency services.

Criteria for determining whether the hospital was the most accessible.

This provision sets forth the factors CMS uses to determine if a nonparticipating hospital was the most accessible facility for emergency services.

Payment to a hospital.

Medicare pays hospitals for emergency services provided they elect to claim payment, submit required claims, and provide evidence of service eligibility.

Payment to the beneficiary.

Medicare pays the beneficiary for emergency services when the hospital has not elected to claim payment directly and the beneficiary submits a valid claim and itemized bill.

General procedures.

Providers must obtain and maintain signed certification and recertification statements from authorized practitioners to verify the necessity of services for Medicare payment.

Scope.

This subpart defines the conditions under which Medicare pays for services furnished in a foreign country.

Scope of payments.

Medicare Part A and Part B coverage for services furnished by foreign hospitals is limited to specific emergency and inpatient scenarios.

Conditions for payment for emergency inpatient hospital services.

Medicare Part A pays for emergency inpatient services in foreign hospitals if the hospital is closer or more accessible than a US facility and meets specific licensing and emergency criteria.

Conditions for payment for nonemergency inpatient services furnished by a hospital closer to the individual's residence.

Medicare Part A pays for nonemergency inpatient services in foreign hospitals if the hospital is closer to the US resident's home and meets specific accreditation standards.

Conditions for payment for physician services and ambulance services.

Medicare Part B covers physician and ambulance services furnished in connection with covered foreign inpatient hospital care if specific conditions are met.

Payment to the hospital.

Medicare pays foreign hospitals for covered services if they elect to claim payment, submit required claims, and provide evidence of service eligibility.

Payment to the beneficiary.

Medicare pays the beneficiary for foreign inpatient and Part B services if the hospital does not elect to claim payment and the beneficiary submits a valid claim and itemized bill.

Requirements for inpatient services of hospitals other than inpatient psychiatric facilities.

This provision establishes the physician certification and recertification requirements for Medicare Part A payment for inpatient hospital services.

Requirements for inpatient services of inpatient psychiatric facilities.

This provision outlines the specific physician certification and recertification requirements for Medicare payment for inpatient psychiatric facility services.

Requirements for inpatient CAH services.

This provision specifies the physician certification requirements for Medicare payment for inpatient services provided by Critical Access Hospitals.

Timing of certification for individual admitted to a hospital before entitlement to Medicare benefits.

This provision defines the timing rules for physician certification and recertification when a patient becomes Medicare-eligible during an inpatient hospital stay.

Requirements for posthospital SNF care.

This provision details the certification and recertification requirements for Medicare payment for posthospital skilled nursing facility care, including swing-bed hospital services.

Scope.

This provision defines the scope of the subpart regarding Medicare Diabetes Prevention Program suppliers and beneficiary engagement incentives.

Requirements for Medicare Diabetes Prevention Program suppliers.

This provision establishes the enrollment, operational, documentation, and coach eligibility standards for suppliers participating in the Medicare Diabetes Prevention Program.

Beneficiary engagement incentives under the Medicare Diabetes Prevention Program expanded model.

This provision establishes the conditions, documentation requirements, and clinical goals for furnishing in-kind beneficiary engagement incentives to Medicare Diabetes Prevention Program beneficiaries.

Requirements for home health services.

Medicare Part A or Part B pays for home health services only if a physician or allowed practitioner as defined at § 484.2 of this chapter certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as...

Requirements for medical and other health services furnished by providers under Medicare Part B.

This provision outlines the physician certification and recertification requirements for various outpatient services, including therapy, intensive outpatient, and partial hospitalization programs.

Requirements for comprehensive outpatient rehabilitation facility (CORF) services.

This provision specifies the physician certification and recertification requirements for services provided by comprehensive outpatient rehabilitation facilities.

Definitions.

This provision provides definitions for terms used in the Medicare payment conditions, including coding systems and hospital participation status.

Scope.

This provision defines the scope of claim filing requirements for Medicare payments, including specific instructions for IME, GME, and DSH payment adjustments.

Basic requirements for all claims.

This provision establishes the mandatory requirements for filing Medicare claims, including electronic submission standards, diagnostic coding, and specific exceptions for small providers.

Additional requirements: Claims for services of providers and claims by suppliers and nonparticipating hospitals.

This provision mandates that claims for services provided by hospitals and suppliers must be filed and signed by the entity unless otherwise waived by CMS.

Additional requirements: Beneficiary's claim for direct payment.

This provision specifies the required content for itemized bills or reports of services when a beneficiary submits a claim for direct payment for services furnished by a hospital or supplier.

Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.

This provision outlines the responsibilities and procedures for replacing U.S. Government and commercial bank checks issued by CMS or its intermediaries.

Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements.

This provision details the specific steps intermediaries and carriers must take when a payee reports a check as lost, stolen, or forged, including bank coordination and replacement timelines.

Signature requirements.

This provision defines who is authorized to sign a Medicare claim on behalf of a beneficiary, including specific procedures for incapacitated patients and ambulance services.

Evidence of authority to sign on behalf of the beneficiary.

This provision requires that individuals signing claims on behalf of a beneficiary provide a statement explaining their relationship and the circumstances necessitating their signature.

Request for payment effective for more than one claim.

This provision outlines the requirements for using a single signed request for payment statement to cover multiple claims for inpatient, outpatient, and home health services.

Time limits for filing claims.

This provision establishes the mandatory timeframes for filing Medicare claims and specifies the limited exceptions under which these deadlines may be extended.

Basic conditions.

This provision defines the fundamental requirements that must be met for services to be eligible for Medicare payment, including coverage, provider qualification, and certification of need.

Scope.

This provision defines the scope of the subpart regarding to whom Medicare payment is made and identifies where special payment situations are addressed.

Scope.

This provision outlines the requirements for provider enrollment, revalidation, and reporting changes to enrollment information for Medicare billing purposes.

Definitions.

As used in this subpart, unless the context indicates otherwise—

Basic enrollment requirement.

This provision mandates that providers and suppliers must be enrolled in the Medicare program to receive payment for covered items or services.

National Provider Identifier (NPI) on all enrollment applications and claims.

This provision requires providers to report their National Provider Identifier (NPI) on enrollment applications and all submitted claims to ensure proper identification.

Ordering covered items and services for Medicare beneficiaries.

This provision establishes the requirements for physicians and eligible professionals to be enrolled in Medicare to order covered imaging, clinical laboratory services, DMEPOS, home health, and hospice services.

Payment to the provider.

This provision outlines the basic rules for Medicare payment to providers and specifies exceptions for outpatient hospital services.

Requirements for enrolling in the Medicare program.

This provision details the enrollment requirements for providers and suppliers, including application submission, documentation, signature authority, and on-site review processes.

Application fee.

This provision establishes the requirement for institutional providers to submit an application fee or a hardship exception request when enrolling or revalidating Medicare billing privileges.

Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.

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.

Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.

This provision outlines requirements for providers to certify compliance, report changes in enrollment information, and maintain documentation for seven years.

Onsite review.

This provision authorizes CMS to conduct onsite reviews of providers to verify enrollment information and ensure compliance with Medicare requirements.

Screening levels for Medicare providers and suppliers.

A Medicare contractor is required to screen all initial applications, revalidation applications, change of ownership applications pursuant to 42 CFR 489.18, applications to add a new practice location, and applications to report any new...

Disclosure of affiliations.

This provision requires providers to disclose affiliations with other entities that have had disclosable events to allow CMS to assess potential risks of fraud, waste, or abuse.

Payment to a nonparticipating hospital.

Medicare pays a nonparticipating hospital for covered emergency inpatient and outpatient services or certain medical services under specific conditions.

Effective date of Medicare billing privileges.

This section specifies the effective dates for Medicare billing privileges for various provider and supplier types, including hospitals and clinical labs.

Request for payment by certain provider and supplier types.

This section outlines the conditions under which certain providers and suppliers may retrospectively bill for services provided prior to their Medicare enrollment effective date.

Additional effective dates.

This section specifies the effective dates for reassignment of benefits and Form CMS-855O enrollment.

Rejection of a provider's or supplier's application for Medicare enrollment.

This section details the reasons CMS may reject a Medicare enrollment application and the process for resubmission.

Return of a provider's or supplier's enrollment application.

This section lists the specific reasons CMS may return a Medicare enrollment application without processing.

Provisional period of enhanced oversight.

This section defines the criteria for a provisional period of enhanced oversight for new providers or suppliers and the effective date of such oversight.

Payment to the beneficiary.

This section specifies the circumstances under which Medicare makes payment directly to the beneficiary for services furnished by nonparticipating hospitals or suppliers.

Denial of enrollment in the Medicare program.

This provision outlines the specific grounds upon which CMS may deny a provider or supplier's enrollment in the Medicare program, including noncompliance, criminal history, financial debt, and false information, while detailing the processes for reapplication and potential reapplication bars.

Revocation of enrollment in the Medicare program.

This provision outlines the specific grounds, processes, and consequences for the revocation of a provider or supplier's Medicare enrollment, including reenrollment bars and the impact on provider agreements.

Payment to the beneficiary's legal guardian or representative payee.

Medicare may pay amounts due a beneficiary to the beneficiary's legal guardian or representative payee.

Deactivation of Medicare billing privileges.

CMS may deactivate a provider's Medicare billing privileges for reasons such as inactivity, failure to update enrollment information, or non-compliance.

Stay of enrollment.

CMS may impose a stay on a provider's enrollment for non-compliance, which results in the rejection of claims during the stay period.

Prohibition on ordering, certifying, referring, or prescribing based on felony conviction.

Medicare prohibits payment for services ordered or prescribed by professionals with certain felony convictions within the previous 10 years.

Provider and supplier appeal rights.

Providers may appeal CMS decisions regarding enrollment denial or revocation, with specific procedures for handling billing privilege and provider agreement terminations.

Deactivation rebuttals.

Providers have 15 days to submit a written rebuttal to CMS following the deactivation of their Medicare billing privileges.

Deactivation based on ordering, certifying, or referring services and items.

CMS may deactivate a practitioner's ability to order, certify, or refer Medicare services if they have not been listed on a claim in the previous 12 months.

Payment to the supplier.

This provision outlines the conditions under which Medicare pays suppliers for covered services, including assignment requirements and limitations on beneficiary charges.

Prohibitions on the sale or transfer of billing privileges.

This provision prohibits the sale or unauthorized use of Medicare billing numbers and mandates specific enrollment procedures during changes of ownership.

DMEPOS supplier changes in majority ownership.

This provision defines requirements for DMEPOS suppliers undergoing changes in majority ownership, including mandatory re-enrollment and accreditation.

Payment liability.

This provision establishes that Medicare payment is contingent upon valid billing privileges and outlines financial liability for services furnished by ineligible suppliers.

Payment to a beneficiary and to a supplier.

This provision specifies the methodology for split payments between beneficiaries and suppliers when claims are assigned after partial payment.

Overpayment.

This provision mandates that failure to comply with specific reporting requirements results in an overpayment assessment back to the date of the adverse action or change.

Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.

This provision establishes the enrollment, accreditation, surety bond, and operational standards that DMEPOS suppliers must meet to maintain Medicare billing privileges and receive payment.

Moratoria on newly enrolling Medicare providers and suppliers.

CMS may impose temporary moratoria on the enrollment of new Medicare providers or suppliers in specific geographic areas or categories to mitigate risks of fraud, waste, or abuse.

Rural emergency hospitals.

Rural emergency hospitals must comply with Medicare enrollment requirements and may convert existing hospital or critical access hospital enrollment via a change of information application.

Accreditation.

This regulation establishes the requirements for CMS-approved accrediting organizations for DMEPOS suppliers, including application procedures, ongoing oversight, complaint handling, and conflict of interest standards.

Scope.

This provision defines the scope of regulations governing Medicare payments made after a beneficiary's death and payments to entities providing complementary coverage.

Payment after beneficiary's death: Bill has been paid.

This provision specifies the conditions and priority for Medicare reimbursement when a beneficiary dies after having paid for covered services.

Payment after beneficiary's death: Bill has not been paid.

This provision outlines the requirements for Medicare payment to suppliers or other responsible parties when a beneficiary dies before a bill is paid.

Payment to entities that provide coverage complementary to Medicare Part B.

This provision establishes the conditions under which Medicare may pay entities that provide health benefit plans complementary to Medicare Part B.

Enrollment requirements for opioid treatment programs (OTP).

This provision establishes the Medicare enrollment requirements, screening standards, and compliance obligations for opioid treatment programs.

Enrollment requirements for home infusion therapy suppliers.

This provision defines the requirements for home infusion therapy suppliers to enroll in and receive payment from the Medicare program.

General limitations.

This provision outlines limitations on Medicare payment for inpatient hospital services based on utilization review findings regarding medical necessity.

Basis and scope.

This provision establishes the statutory basis and scope for regulations prohibiting the assignment or transfer of Medicare payments.

Definitions.

This provision provides definitions for terms used in the subpart regarding the assignment of Medicare claims.

Prohibition of assignment of claims by providers.

This provision prohibits the assignment of Medicare payments to third parties, with specific exceptions for government entities and billing agents.

Termination of provider agreement.

This provision outlines the grounds for terminating a provider agreement if a provider violates payment assignment prohibitions.

Prohibition of reassignment of claims by suppliers.

This provision establishes the general prohibition against the reassignment of Medicare claims by suppliers, while outlining specific exceptions for employers, contractual entities, and court-ordered arrangements.

Revocation of right to receive assigned benefits.

This provision defines the conditions and procedures under which CMS may revoke a supplier's or other party's right to receive Medicare payments.

Hearings on revocation of right to receive assigned benefits.

This provision outlines the administrative hearing process for suppliers or other parties contesting a CMS revocation of their right to receive assigned Medicare benefits.

Final determination on revocation of right to receive assigned benefits.

This provision specifies the process for reaching a final determination regarding the revocation of the right to receive assigned Medicare benefits, including the effect of such determinations.

Prohibition of assignment of claims by beneficiaries.

This provision establishes the general prohibition against the assignment of Medicare claims by beneficiaries, with limited exceptions for government agencies and court-ordered assignments.

Court ordered assignments: Conditions and limitations.

This provision sets forth the conditions, limitations, and liability requirements for Medicare payments made under court-ordered assignments or reassignments.