42:2.0.1.2.12.1 | SUBPART A
| Subpart A - General Exclusions and Exclusion of Particular Services | |
42:2.0.1.2.12.1.35.1 | SECTION 411.1
| 411.1 Basis and scope. | |
42:2.0.1.2.12.1.35.2 | SECTION 411.2
| 411.2 Conclusive effect of QIO determinations on payment of claims. | |
42:2.0.1.2.12.1.35.3 | SECTION 411.4
| 411.4 Services for which neither the beneficiary nor any other person is legally obligated to pay. | |
42:2.0.1.2.12.1.35.4 | SECTION 411.6
| 411.6 Services furnished by a Federal provider of services or other Federal agency. | |
42:2.0.1.2.12.1.35.5 | SECTION 411.7
| 411.7 Services that must be furnished at public expense under a Federal law or Federal Government contract. | |
42:2.0.1.2.12.1.35.6 | SECTION 411.8
| 411.8 Services paid for by a Government entity. | |
42:2.0.1.2.12.1.35.7 | SECTION 411.9
| 411.9 Services furnished outside the United States. | |
42:2.0.1.2.12.1.35.8 | SECTION 411.10
| 411.10 Services required as a result of war. | |
42:2.0.1.2.12.1.35.9 | SECTION 411.12
| 411.12 Charges imposed by an immediate relative or member of the beneficiary's household. | |
42:2.0.1.2.12.1.35.10 | SECTION 411.15
| 411.15 Particular services excluded from coverage. | |
42:2.0.1.2.12.2 | SUBPART B
| Subpart B - Insurance Coverage That Limits Medicare Payment: General Provisions | |
42:2.0.1.2.12.2.35.1 | SECTION 411.20
| 411.20 Basis and scope. | |
42:2.0.1.2.12.2.35.2 | SECTION 411.21
| 411.21 Definitions. | |
42:2.0.1.2.12.2.35.3 | SECTION 411.22
| 411.22 Reimbursement obligations of primary payers and entities that received payment from primary payers. | |
42:2.0.1.2.12.2.35.4 | SECTION 411.23
| 411.23 Beneficiary's cooperation. | |
42:2.0.1.2.12.2.35.5 | SECTION 411.24
| 411.24 Recovery of conditional payments. | |
42:2.0.1.2.12.2.35.6 | SECTION 411.25
| 411.25 Primary payer's notice of primary payment responsibility. | |
42:2.0.1.2.12.2.35.7 | SECTION 411.26
| 411.26 Subrogation and right to intervene. | |
42:2.0.1.2.12.2.35.8 | SECTION 411.28
| 411.28 Waiver of recovery and compromise of claims. | |
42:2.0.1.2.12.2.35.9 | SECTION 411.30
| 411.30 Effect of primary payment on benefit utilization and deductibles. | |
42:2.0.1.2.12.2.35.10 | SECTION 411.31
| 411.31 Authority to bill primary payers for full charges. | |
42:2.0.1.2.12.2.35.11 | SECTION 411.32
| 411.32 Basis for Medicare secondary payments. | |
42:2.0.1.2.12.2.35.12 | SECTION 411.33
| 411.33 Amount of Medicare secondary payment. | |
42:2.0.1.2.12.2.35.13 | SECTION 411.35
| 411.35 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. | |
42:2.0.1.2.12.2.35.14 | SECTION 411.37
| 411.37 Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement. | |
42:2.0.1.2.12.2.35.15 | SECTION 411.39
| 411.39 Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal. | |
42:2.0.1.2.12.3 | SUBPART C
| Subpart C - Limitations on Medicare Payment for Services Covered Under Workers' Compensation | |
42:2.0.1.2.12.3.35.1 | SECTION 411.40
| 411.40 General provisions. | |
42:2.0.1.2.12.3.35.2 | SECTION 411.43
| 411.43 Beneficiary's responsibility with respect to workers' compensation. | |
42:2.0.1.2.12.3.35.3 | SECTION 411.45
| 411.45 Basis for conditional Medicare payment in workers' compensation cases. | |
42:2.0.1.2.12.3.35.4 | SECTION 411.46
| 411.46 Lump-sum payments. | |
42:2.0.1.2.12.3.35.5 | SECTION 411.47
| 411.47 Apportionment of a lump-sum compromise settlement of a workers' compensation claim. | |
42:2.0.1.2.12.4 | SUBPART D
| Subpart D - Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance | |
42:2.0.1.2.12.4.35.1 | SECTION 411.50
| 411.50 General provisions. | |
42:2.0.1.2.12.4.35.2 | SECTION 411.51
| 411.51 Beneficiary's responsibility with respect to no-fault insurance. | |
42:2.0.1.2.12.4.35.3 | SECTION 411.52
| 411.52 Basis for conditional Medicare payment in liability cases. | |
42:2.0.1.2.12.4.35.4 | SECTION 411.53
| 411.53 Basis for conditional Medicare payment in no-fault cases. | |
42:2.0.1.2.12.4.35.5 | SECTION 411.54
| 411.54 Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer. | |
42:2.0.1.2.12.5 | SUBPART E
| Subpart E - Limitations on Payment for Services Covered Under Group Health Plans: General Provisions | |
42:2.0.1.2.12.5.35.1 | SECTION 411.100
| 411.100 Basis and scope. | |
42:2.0.1.2.12.5.35.2 | SECTION 411.101
| 411.101 Definitions. | |
42:2.0.1.2.12.5.35.3 | SECTION 411.102
| 411.102 Basic prohibitions and requirements. | |
42:2.0.1.2.12.5.35.4 | SECTION 411.103
| 411.103 Prohibition against financial and other incentives. | |
42:2.0.1.2.12.5.35.5 | SECTION 411.104
| 411.104 Current employment status. | |
42:2.0.1.2.12.5.35.6 | SECTION 411.106
| 411.106 Aggregation rules. | |
42:2.0.1.2.12.5.35.7 | SECTION 411.108
| 411.108 Taking into account entitlement to Medicare. | |
42:2.0.1.2.12.5.35.8 | SECTION 411.110
| 411.110 Basis for determination of nonconformance. | |
42:2.0.1.2.12.5.35.9 | SECTION 411.112
| 411.112 Documentation of conformance. | |
42:2.0.1.2.12.5.35.10 | SECTION 411.114
| 411.114 Determination of nonconformance. | |
42:2.0.1.2.12.5.35.11 | SECTION 411.115
| 411.115 Notice of determination of nonconformance. | |
42:2.0.1.2.12.5.35.12 | SECTION 411.120
| 411.120 Appeals. | |
42:2.0.1.2.12.5.35.13 | SECTION 411.121
| 411.121 Hearing procedures. | |
42:2.0.1.2.12.5.35.14 | SECTION 411.122
| 411.122 Hearing officer's decision. | |
42:2.0.1.2.12.5.35.15 | SECTION 411.124
| 411.124 Administrator's review of hearing decision. | |
42:2.0.1.2.12.5.35.16 | SECTION 411.126
| 411.126 Reopening of determinations and decisions. | |
42:2.0.1.2.12.5.35.17 | SECTION 411.130
| 411.130 Referral to Internal Revenue Service (IRS). | |
42:2.0.1.2.12.6 | SUBPART F
| Subpart F - Special Rules: Individuals Eligible or Entitled on the Basis of ESRD, Who Are Also Covered Under Group Health Plans | |
42:2.0.1.2.12.6.35.1 | SECTION 411.160
| 411.160 Scope. | |
42:2.0.1.2.12.6.35.2 | SECTION 411.161
| 411.161 Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits. | |
42:2.0.1.2.12.6.35.3 | SECTION 411.162
| 411.162 Medicare benefits secondary to group health plan benefits. | |
42:2.0.1.2.12.6.35.4 | SECTION 411.163
| 411.163 Coordination of benefits: Dual entitlement situations. | |
42:2.0.1.2.12.6.35.5 | SECTION 411.165
| 411.165 Basis for conditional Medicare payments. | |
42:2.0.1.2.12.7 | SUBPART G
| Subpart G - Special Rules: Aged Beneficiaries and Spouses Who Are Also Covered Under Group Health Plans | |
42:2.0.1.2.12.7.35.1 | SECTION 411.170
| 411.170 General provisions. | |
42:2.0.1.2.12.7.35.2 | SECTION 411.172
| 411.172 Medicare benefits secondary to group health plan benefits. | |
42:2.0.1.2.12.7.35.3 | SECTION 411.175
| 411.175 Basis for Medicare primary payments. | |
42:2.0.1.2.12.8 | SUBPART H
| Subpart H - Special Rules: Disabled Beneficiaries Who Are Also Covered Under Large Group Health Plans | |
42:2.0.1.2.12.8.35.1 | SECTION 411.200
| 411.200 Basis. | |
42:2.0.1.2.12.8.35.2 | SECTION 411.201
| 411.201 Definitions. | |
42:2.0.1.2.12.8.35.3 | SECTION 411.204
| 411.204 Medicare benefits secondary to LGHP benefits. | |
42:2.0.1.2.12.8.35.4 | SECTION 411.206
| 411.206 Basis for Medicare primary payments and limits on secondary payments. | |
42:2.0.1.2.12.9 | SUBPART I
| Subpart I [Reserved] | |
42:2.0.1.2.12.10 | SUBPART J
| Subpart J - Financial Relationships Between Physicians and Entities Furnishing Designated Health Services | |
42:2.0.1.2.12.10.35.1 | SECTION 411.350
| 411.350 Scope of subpart. | |
42:2.0.1.2.12.10.35.2 | SECTION 411.351
| 411.351 Definitions. | |
42:2.0.1.2.12.10.35.3 | SECTION 411.352
| 411.352 Group practice. | |
42:2.0.1.2.12.10.35.4 | SECTION 411.353
| 411.353 Prohibition on certain referrals by physicians and limitations on billing. | |
42:2.0.1.2.12.10.35.5 | SECTION 411.354
| 411.354 Financial relationship, compensation, and ownership or investment interest. | |
42:2.0.1.2.12.10.35.6 | SECTION 411.355
| 411.355 General exceptions to the referral prohibition related to both ownership/investment and compensation. | |
42:2.0.1.2.12.10.35.7 | SECTION 411.356
| 411.356 Exceptions to the referral prohibition related to ownership or investment interests. | |
42:2.0.1.2.12.10.35.8 | SECTION 411.357
| 411.357 Exceptions to the referral prohibition related to compensation arrangements. | |
42:2.0.1.2.12.10.35.9 | SECTION 411.361
| 411.361 Reporting requirements. | |
42:2.0.1.2.12.10.35.10 | SECTION 411.362
| 411.362 Additional requirements concerning physician ownership and investment in hospitals. | |
42:2.0.1.2.12.10.35.11 | SECTION 411.370
| 411.370 Advisory opinions relating to physician referrals. | |
42:2.0.1.2.12.10.35.12 | SECTION 411.372
| 411.372 Procedure for submitting a request. | |
42:2.0.1.2.12.10.35.13 | SECTION 411.373
| 411.373 Certification. | |
42:2.0.1.2.12.10.35.14 | SECTION 411.375
| 411.375 Fees for the cost of advisory opinions. | |
42:2.0.1.2.12.10.35.15 | SECTION 411.377
| 411.377 Expert opinions from outside sources. | |
42:2.0.1.2.12.10.35.16 | SECTION 411.378
| 411.378 Withdrawing a request. | |
42:2.0.1.2.12.10.35.17 | SECTION 411.379
| 411.379 When CMS accepts a request. | |
42:2.0.1.2.12.10.35.18 | SECTION 411.380
| 411.380 When CMS issues a formal advisory opinion. | |
42:2.0.1.2.12.10.35.19 | SECTION 411.382
| 411.382 CMS' right to rescind advisory opinions. | |
42:2.0.1.2.12.10.35.20 | SECTION 411.384
| 411.384 Disclosing advisory opinions and supporting information. | |
42:2.0.1.2.12.10.35.21 | SECTION 411.386
| 411.386 CMS's advisory opinions as exclusive. | |
42:2.0.1.2.12.10.35.22 | SECTION 411.387
| 411.387 Effect of an advisory opinion. | |
42:2.0.1.2.12.10.35.23 | SECTION 411.388
| 411.388 When advisory opinions are not admissible evidence. | |
42:2.0.1.2.12.10.35.24 | SECTION 411.389
| 411.389 Range of the advisory opinion. | |
42:2.0.1.2.12.11 | SUBPART K
| Subpart K - Payment for Certain Excluded Services | |
42:2.0.1.2.12.11.35.1 | SECTION 411.400
| 411.400 Payment for custodial care and services not reasonable and necessary. | |
42:2.0.1.2.12.11.35.2 | SECTION 411.402
| 411.402 Indemnification of beneficiary. | |
42:2.0.1.2.12.11.35.3 | SECTION 411.404
| 411.404 Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary. | |
42:2.0.1.2.12.11.35.4 | SECTION 411.406
| 411.406 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. | |
42:2.0.1.2.12.11.35.5 | SECTION 411.408
| 411.408 Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis. | |