Title 42, Part 411 — Exclusions From Medicare and Limitations on Medicare Payment

Basis and scope.

Conclusive effect of QIO determinations on payment of claims.

Items and 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.

Basis and scope.

Definitions.

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 primary payment responsibility.

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.

Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal.

General provisions.

Beneficiary's responsibility with respect to workers' compensation.

Basis for conditional Medicare payment in workers' compensation cases.

Lump-sum payments.

Apportionment of a lump-sum compromise settlement of a workers' compensation claim.

General provisions.

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.

Basis and scope.

Definitions.

Basic prohibitions and requirements.

Prohibition against financial and other incentives.

Current employment status.

Aggregation rules.

Taking into account entitlement to Medicare.

Basis for determination of nonconformance.

Documentation of conformance.

Determination of nonconformance.

Notice of determination of nonconformance.

Appeals.

Hearing procedures.

Hearing officer's decision.

Administrator's review of hearing decision.

Reopening of determinations and decisions.

Referral to Internal Revenue Service (IRS).

Scope.

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.

General provisions.

Medicare benefits secondary to group health plan benefits.

Basis for Medicare primary payments.

Basis.

Definitions.

Medicare benefits secondary to LGHP benefits.

Basis for Medicare primary payments and limits on secondary payments.

Scope of subpart.

Definitions.

Group practice.

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.

Reporting requirements.

Additional requirements concerning physician ownership and investment in hospitals.

Process for requesting an exception from the prohibition on facility expansion.

Advisory opinions relating to physician referrals.

Procedure for submitting a request.

Certification.

Fees for the cost of advisory opinions.

Expert opinions from outside sources.

Withdrawing a request.

When CMS accepts a request.

When CMS issues a formal advisory opinion.

CMS' right to rescind advisory opinions.

Disclosing advisory opinions and supporting information.

CMS's advisory opinions as exclusive.

Effect of an advisory opinion.

When advisory opinions are not admissible evidence.

Range of the advisory opinion.

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.