e-CFR data is current as of July 6, 2020
TITLE 42—Public Health
CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) SUBCHAPTER B—MEDICARE PROGRAM (CONTINUED) PART 424—CONDITIONS FOR MEDICARE PAYMENT
Subpart A—GENERAL PROVISIONS
Subpart B—CERTIFICATION AND PLAN REQUIREMENTS
|
| 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. |
|
Subpart C—CLAIMS FOR PAYMENT
|
| 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. |
|
|
| Evidence of authority to sign on behalf of the beneficiary. |
|
|
| Request for payment effective for more than one claim. |
|
|
| Time limits for filing claims. |
|
Subpart D—TO WHOM PAYMENT IS ORDINARILY MADE
|
| Payment to a nonparticipating hospital. |
|
|
| Payment to the beneficiary. |
|
|
| Payment to the beneficiary's legal guardian or representative payee. |
|
|
| Payment to a beneficiary and to a supplier. |
|
|
| Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges. |
|
Subpart E—TO WHOM PAYMENT IS MADE IN SPECIAL SITUATIONS
|
| 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). |
|
Subpart F—LIMITATIONS ON ASSIGNMENT AND REASSIGNMENT OF CLAIMS
|
| 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. |
|
Subpart G—SPECIAL CONDITIONS: EMERGENCY SERVICES FURNISHED BY A NONPARTICIPATING HOSPITAL
|
| 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 the beneficiary. |
|
Subpart H—SPECIAL CONDITIONS: SERVICES FURNISHED IN A FOREIGN COUNTRY
|
| 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 beneficiary. |
|
Subpart I—REQUIREMENTS FOR MEDICARE DIABETES PREVENTION PROGRAM SUPPLIERS AND BENEFICIARY ENGAGEMENT INCENTIVES UNDER THE MEDICARE DIABETES PREVENTION PROGRAM EXPANDED MODEL
|
| Requirements for Medicare Diabetes Prevention Program suppliers. |
|
|
| Beneficiary engagement incentives under the Medicare Diabetes Prevention Program expanded model. |
|
Subparts J-L [Reserved]
Subpart M—REPLACEMENT AND RECLAMATION OF MEDICARE PAYMENTS
|
| 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. |
|
Subparts N-O [Reserved]
Subpart P—REQUIREMENTS FOR ESTABLISHING AND MAINTAINING MEDICARE BILLING PRIVILEGES
|
| 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. |
|
|
| 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. |
|
|
| Screening levels for Medicare providers and suppliers. |
|
|
| Disclosure of affiliations. |
|
|
| Effective date of Medicare billing privileges. |
|
|
| Request for payment by physicians, non-physician practitioners, physician and non-physician organizations, ambulance suppliers, and opioid treatment programs. |
|
|
| Rejection of a provider or supplier's enrollment application for Medicare enrollment. |
|
|
| Denial of enrollment in the Medicare program. |
|
|
| Revocation of enrollment in the Medicare program. |
|
|
| Deactivation of Medicare billing privileges. |
|
|
| Provider and supplier appeal rights. |
|
|
| Prohibitions on the sale or transfer of billing privileges. |
|
|
| Moratoria on newly enrolling Medicare providers and suppliers. |
|
| 