Title 42, Part 424 — Conditions for Medicare Payment

Basis and scope.

Definitions.

Basic conditions.

General limitations.

Purpose and scope.

General procedures.

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

Requirements for inpatient services of inpatient psychiatric facilities.

Requirements for inpatient CAH services.

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

Requirements for posthospital SNF care.

Requirements for home health services.

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

Requirements for comprehensive outpatient rehabilitation facility (CORF) services.

Scope.

Basic requirements for all claims.

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

Additional requirements: Beneficiary's claim for direct payment.

Signature requirements.

Evidence of authority to sign on behalf of the beneficiary.

Request for payment effective for more than one claim.

Time limits for filing claims.

Scope.

Payment to the provider.

Payment to a nonparticipating hospital.

Payment to the beneficiary.

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

Payment to the supplier.

Payment to a beneficiary and to a supplier.

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

Accreditation.

Scope.

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

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

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

Enrollment requirements for opioid treatment programs (OTP).

Enrollment requirements for home infusion therapy suppliers.

Basis and scope.

Definitions.

Prohibition of assignment of claims by providers.

Termination of provider agreement.

Prohibition of reassignment of claims by suppliers.

Revocation of right to receive assigned benefits.

Hearings on revocation of right to receive assigned benefits.

Final determination on revocation of right to receive assigned benefits.

Prohibition of assignment of claims by beneficiaries.

Court ordered assignments: Conditions and limitations.

Scope.

Definitions.

Situations that do not constitute an emergency.

Conditions for payment for emergency services.

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

Criteria for determining whether the hospital was the most accessible.

Payment to a hospital.

Payment to the beneficiary.

Scope.

Scope of payments.

Conditions for payment for emergency inpatient hospital services.

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

Conditions for payment for physician services and ambulance services.

Payment to the hospital.

Payment to the beneficiary.

Scope.

Requirements for Medicare Diabetes Prevention Program suppliers.

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

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

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

Scope.

Definitions.

Basic enrollment requirement.

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

Ordering covered items and services for Medicare beneficiaries.

Requirements for enrolling in the Medicare program.

Application fee.

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

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

Onsite review.

Screening levels for Medicare providers and suppliers.

Disclosure of affiliations.

Effective date of Medicare billing privileges.

Request for payment by certain provider and supplier types.

Additional effective dates.

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

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

Provisional period of enhanced oversight.

Denial of enrollment in the Medicare program.

Revocation of enrollment in the Medicare program.

Deactivation of Medicare billing privileges.

Stay of enrollment.

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

Provider and supplier appeal rights.

Deactivation rebuttals.

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

Prohibitions on the sale or transfer of billing privileges.

DMEPOS supplier changes in majority ownership.

Payment liability.

Overpayment.

Moratoria on newly enrolling Medicare providers and suppliers.

Rural emergency hospitals.