42 C.F.R. PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
Subpart A--GENERAL EXCLUSIONS AND EXCLUSION OF PARTICULAR SERVICES
|
|
| Conclusive effect of QIO determinations on payment of claims.
|
|
|
|
| Services for which neither the beneficiary nor any other person is legally obligated to pay.
|
|
|
|
| Services furnished by a Federal provider of services or other Federal agency.
|
|
|
|
| Services that must be furnished at public expense under a Federal law or Federal Government contract.
|
|
|
|
| Services paid for by a Government entity.
|
|
|
|
| Services furnished outside the United States.
|
|
|
|
| Services required as a result of war.
|
|
|
|
| Charges imposed by an immediate relative or member of the beneficiary's household.
|
|
|
|
| Particular services excluded from coverage.
|
|
Subpart B--INSURANCE COVERAGE THAT LIMITS MEDICARE PAYMENT: GENERAL PROVISIONS
|
|
| Reimbursement obligations of primary payers and entities that received payment from primary payers.
|
|
|
|
| Beneficiary's cooperation.
|
|
|
|
| Recovery of conditional payments.
|
|
|
|
| Primary payer's notice of mistaken Medicare primary payment.
|
|
|
|
| Subrogation and right to intervene.
|
|
|
|
| Waiver of recovery and compromise of claims.
|
|
|
|
| Effect of primary payment on benefit utilization and deductibles.
|
|
|
|
| Authority to bill primary payers for full charges.
|
|
|
|
| Basis for Medicare secondary payments.
|
|
|
|
| Amount of Medicare secondary payment.
|
|
|
|
| Limitations on charges to a beneficiary or other party when a workers' compensation plan, a no-fault insurer, or an employer group health plan is primary payer.
|
|
|
|
| Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.
|
|
Subpart C--LIMITATIONS ON MEDICARE PAYMENT FOR SERVICES COVERED UNDER WORKERS' COMPENSATION
|
|
| Beneficiary's responsibility with respect to workers' compensation.
|
|
|
|
| Basis for conditional Medicare payment in workers' compensation cases.
|
|
|
|
| Apportionment of a lump-sum compromise settlement of a workers' compensation claim.
|
|
Subpart D--LIMITATIONS ON MEDICARE PAYMENT FOR SERVICES COVERED UNDER LIABILITY OR NO-FAULT INSURANCE
|
|
| Beneficiary's responsibility with respect to no-fault insurance.
|
|
|
|
| Basis for conditional Medicare payment in liability cases.
|
|
|
|
| Basis for conditional Medicare payment in no-fault cases.
|
|
|
|
| Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.
|
|
Subpart E--LIMITATIONS ON PAYMENT FOR SERVICES COVERED UNDER GROUP HEALTH PLANS: GENERAL PROVISIONS
|
|
| Basic prohibitions and requirements.
|
|
|
|
| Prohibition against financial and other incentives.
|
|
|
|
| Current employment status.
|
|
|
|
| Taking into account entitlement to Medicare.
|
|
|
|
| Basis for determination of nonconformance.
|
|
|
|
| Documentation of conformance.
|
|
|
|
| Determination of nonconformance.
|
|
|
|
| Notice of determination of nonconformance.
|
|
|
|
| Hearing officer's decision.
|
|
|
|
| Administrator's review of hearing decision.
|
|
|
|
| Reopening of determinations and decisions.
|
|
|
|
| Referral to Internal Revenue Service (IRS).
|
|
Subpart F--SPECIAL RULES: INDIVIDUALS ELIGIBLE OR ENTITLED ON THE BASIS OF ESRD, WHO ARE ALSO COVERED UNDER GROUP HEALTH PLANS
|
|
| Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.
|
|
|
|
| Medicare benefits secondary to group health plan benefits.
|
|
|
|
| Coordination of benefits: Dual entitlement situations.
|
|
|
|
| Basis for conditional Medicare payments.
|
|
Subpart G--SPECIAL RULES: AGED BENEFICIARIES AND SPOUSES WHO ARE ALSO COVERED UNDER GROUP HEALTH PLANS
|
|
| Medicare benefits secondary to group health plan benefits.
|
|
|
|
| Basis for Medicare primary payments.
|
|
Subpart H--SPECIAL RULES: DISABLED BENEFICIARIES WHO ARE ALSO COVERED UNDER LARGE GROUP HEALTH PLANS
|
|
| Medicare benefits secondary to LGHP benefits.
|
|
|
|
| Basis for Medicare primary payments and limits on secondary payments.
|
|
Subpart I--[RESERVED]
Subpart J--FINANCIAL RELATIONSHIPS BETWEEN PHYSICIANS AND ENTITIES FURNISHING DESIGNATED HEALTH SERVICES
|
|
| Prohibition on certain referrals by physicians and limitations on billing.
|
|
|
|
| Financial relationship, compensation, and ownership or investment interest.
|
|
|
|
| General exceptions to the referral prohibition related to both ownership/investment and compensation.
|
|
|
|
| Exceptions to the referral prohibition related to ownership or investment interests.
|
|
|
|
| Exceptions to the referral prohibition related to compensation arrangements.
|
|
|
|
| Advisory opinions relating to physician referrals.
|
|
|
|
| Procedure for submitting a request.
|
|
|
|
| Fees for the cost of advisory opinions.
|
|
|
|
| Expert opinions from outside sources.
|
|
|
|
| When CMS accepts a request.
|
|
|
|
| When CMS issues a formal advisory opinion.
|
|
|
|
| CMS's right to rescind advisory opinions.
|
|
|
|
| Disclosing advisory opinions and supporting information.
|
|
|
|
| CMS's advisory opinions as exclusive.
|
|
|
|
| Parties affected by advisory opinions.
|
|
|
|
| When advisory opinions are not admissible evidence.
|
|
|
|
| Range of the advisory opinion.
|
|
Subpart K--PAYMENT FOR CERTAIN EXCLUDED SERVICES
|
|
| Payment for custodial care and services not reasonable and necessary.
|
|
|
|
| Indemnification of beneficiary.
|
|
|
|
| Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
|
|
|
|
| Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
|
|
|
|
| Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.
|
|