Title 42

PART 424

Part 424 - Conditions For Medicare Payment

PART 424 - CONDITIONS FOR MEDICARE PAYMENT Authority:42 U.S.C. 1302 and 1395hh. Source:53 FR 6634, Mar. 2, 1988, unless otherwise noted.

42:3.0.1.1.11.1SUBPART A
Subpart A - General Provisions
42:3.0.1.1.11.1.9.1SECTION 424.1
   424.1 Basis and scope.
42:3.0.1.1.11.1.9.2SECTION 424.3
   424.3 Definitions.
42:3.0.1.1.11.1.9.3SECTION 424.5
   424.5 Basic conditions.
42:3.0.1.1.11.1.9.4SECTION 424.7
   424.7 General limitations.
42:3.0.1.1.11.2SUBPART B
Subpart B - Certification and Plan Requirements
42:3.0.1.1.11.2.9.1SECTION 424.10
   424.10 Purpose and scope.
42:3.0.1.1.11.2.9.2SECTION 424.11
   424.11 General procedures.
42:3.0.1.1.11.2.9.3SECTION 424.13
   424.13 Requirements for inpatient services of hospitals other than inpatient psychiatric facilities.
42:3.0.1.1.11.2.9.4SECTION 424.14
   424.14 Requirements for inpatient services of inpatient psychiatric facilities.
42:3.0.1.1.11.2.9.5SECTION 424.15
   424.15 Requirements for inpatient CAH services.
42:3.0.1.1.11.2.9.6SECTION 424.16
   424.16 Timing of certification for individual admitted to a hospital before entitlement to Medicare benefits.
42:3.0.1.1.11.2.9.7SECTION 424.20
   424.20 Requirements for posthospital SNF care.
42:3.0.1.1.11.2.9.8SECTION 424.22
   424.22 Requirements for home health services.
42:3.0.1.1.11.2.9.9SECTION 424.24
   424.24 Requirements for medical and other health services furnished by providers under Medicare Part B.
42:3.0.1.1.11.2.9.10SECTION 424.27
   424.27 Requirements for comprehensive outpatient rehabilitation facility (CORF) services.
42:3.0.1.1.11.3SUBPART C
Subpart C - Claims for Payment
42:3.0.1.1.11.3.9.1SECTION 424.30
   424.30 Scope.
42:3.0.1.1.11.3.9.2SECTION 424.32
   424.32 Basic requirements for all claims.
42:3.0.1.1.11.3.9.3SECTION 424.33
   424.33 Additional requirements: Claims for services of providers and claims by suppliers and nonparticipating hospitals.
42:3.0.1.1.11.3.9.4SECTION 424.34
   424.34 Additional requirements: Beneficiary's claim for direct payment.
42:3.0.1.1.11.3.9.5SECTION 424.36
   424.36 Signature requirements.
42:3.0.1.1.11.3.9.6SECTION 424.37
   424.37 Evidence of authority to sign on behalf of the beneficiary.
42:3.0.1.1.11.3.9.7SECTION 424.40
   424.40 Request for payment effective for more than one claim.
42:3.0.1.1.11.3.9.8SECTION 424.44
   424.44 Time limits for filing claims.
42:3.0.1.1.11.4SUBPART D
Subpart D - To Whom Payment Is Ordinarily Made
42:3.0.1.1.11.4.9.1SECTION 424.50
   424.50 Scope.
42:3.0.1.1.11.4.9.2SECTION 424.51
   424.51 Payment to the provider.
42:3.0.1.1.11.4.9.3SECTION 424.52
   424.52 Payment to a nonparticipating hospital.
42:3.0.1.1.11.4.9.4SECTION 424.53
   424.53 Payment to the beneficiary.
42:3.0.1.1.11.4.9.5SECTION 424.54
   424.54 Payment to the beneficiary's legal guardian or representative payee.
42:3.0.1.1.11.4.9.6SECTION 424.55
   424.55 Payment to the supplier.
42:3.0.1.1.11.4.9.7SECTION 424.56
   424.56 Payment to a beneficiary and to a supplier.
42:3.0.1.1.11.4.9.8SECTION 424.57
   424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.
42:3.0.1.1.11.4.9.9SECTION 424.58
   424.58 Accreditation.
42:3.0.1.1.11.5SUBPART E
Subpart E - To Whom Payment is Made in Special Situations
42:3.0.1.1.11.5.9.1SECTION 424.60
   424.60 Scope.
42:3.0.1.1.11.5.9.2SECTION 424.62
   424.62 Payment after beneficiary's death: Bill has been paid.
42:3.0.1.1.11.5.9.3SECTION 424.64
   424.64 Payment after beneficiary's death: Bill has not been paid.
42:3.0.1.1.11.5.9.4SECTION 424.66
   424.66 Payment to entities that provide coverage complementary to Medicare Part B.
42:3.0.1.1.11.5.9.5SECTION 424.67
   424.67 Enrollment requirements for opioid treatment programs (OTP).
42:3.0.1.1.11.6SUBPART F
Subpart F - Limitations on Assignment and Reassignment of Claims
42:3.0.1.1.11.6.9.1SECTION 424.70
   424.70 Basis and scope.
42:3.0.1.1.11.6.9.2SECTION 424.71
   424.71 Definitions.
42:3.0.1.1.11.6.9.3SECTION 424.73
   424.73 Prohibition of assignment of claims by providers.
42:3.0.1.1.11.6.9.4SECTION 424.74
   424.74 Termination of provider agreement.
42:3.0.1.1.11.6.9.5SECTION 424.80
   424.80 Prohibition of reassignment of claims by suppliers.
42:3.0.1.1.11.6.9.6SECTION 424.82
   424.82 Revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.9.7SECTION 424.83
   424.83 Hearings on revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.9.8SECTION 424.84
   424.84 Final determination on revocation of right to receive assigned benefits.
42:3.0.1.1.11.6.9.9SECTION 424.86
   424.86 Prohibition of assignment of claims by beneficiaries.
42:3.0.1.1.11.6.9.10SECTION 424.90
   424.90 Court ordered assignments: Conditions and limitations.
42:3.0.1.1.11.7SUBPART G
Subpart G - Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital
42:3.0.1.1.11.7.9.1SECTION 424.100
   424.100 Scope.
42:3.0.1.1.11.7.9.2SECTION 424.101
   424.101 Definitions.
42:3.0.1.1.11.7.9.3SECTION 424.102
   424.102 Situations that do not constitute an emergency.
42:3.0.1.1.11.7.9.4SECTION 424.103
   424.103 Conditions for payment for emergency services.
42:3.0.1.1.11.7.9.5SECTION 424.104
   424.104 Election to claim payment for emergency services furnished during a calendar year.
42:3.0.1.1.11.7.9.6SECTION 424.106
   424.106 Criteria for determining whether the hospital was the most accessible.
42:3.0.1.1.11.7.9.7SECTION 424.108
   424.108 Payment to a hospital.
42:3.0.1.1.11.7.9.8SECTION 424.109
   424.109 Payment to the beneficiary.
42:3.0.1.1.11.8SUBPART H
Subpart H - Special Conditions: Services Furnished in a Foreign Country
42:3.0.1.1.11.8.9.1SECTION 424.120
   424.120 Scope.
42:3.0.1.1.11.8.9.2SECTION 424.121
   424.121 Scope of payments.
42:3.0.1.1.11.8.9.3SECTION 424.122
   424.122 Conditions for payment for emergency inpatient hospital services.
42:3.0.1.1.11.8.9.4SECTION 424.123
   424.123 Conditions for payment for nonemergency inpatient services furnished by a hospital closer to the individual's residence.
42:3.0.1.1.11.8.9.5SECTION 424.124
   424.124 Conditions for payment for physician services and ambulance services.
42:3.0.1.1.11.8.9.6SECTION 424.126
   424.126 Payment to the hospital.
42:3.0.1.1.11.8.9.7SECTION 424.127
   424.127 Payment to the beneficiary.
42:3.0.1.1.11.9SUBPART I
Subpart I - Requirements for Medicare Diabetes Prevention Program Suppliers and Beneficiary Engagement Incentives Under the Medicare Diabetes Prevention Program Expanded Model
42:3.0.1.1.11.9.9.1SECTION 424.200
   424.200 Scope.
42:3.0.1.1.11.9.9.2SECTION 424.205
   424.205 Requirements for Medicare Diabetes Prevention Program suppliers.
42:3.0.1.1.11.9.9.3SECTION 424.210
   424.210 Beneficiary engagement incentives under the Medicare Diabetes Prevention Program expanded model.
42:3.0.1.1.11.10SUBPART J
Subparts J-L [Reserved]
42:3.0.1.1.11.11SUBPART M
Subpart M - Replacement and Reclamation of Medicare Payments
42:3.0.1.1.11.11.9.1SECTION 424.350
   424.350 Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements.
42:3.0.1.1.11.11.9.2SECTION 424.352
   424.352 Intermediary and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements.
42:3.0.1.1.11.12SUBPART N
Subparts N-O [Reserved]
42:3.0.1.1.11.13SUBPART P
Subpart P - Requirements for Establishing and Maintaining Medicare Billing Privileges
42:3.0.1.1.11.13.9.1SECTION 424.500
   424.500 Scope.
42:3.0.1.1.11.13.9.2SECTION 424.502
   424.502 Definitions.
42:3.0.1.1.11.13.9.3SECTION 424.505
   424.505 Basic enrollment requirement.
42:3.0.1.1.11.13.9.4SECTION 424.506
   424.506 National Provider Identifier (NPI) on all enrollment applications and claims.
42:3.0.1.1.11.13.9.5SECTION 424.507
   424.507 Ordering covered items and services for Medicare beneficiaries.
42:3.0.1.1.11.13.9.6SECTION 424.510
   424.510 Requirements for enrolling in the Medicare program.
42:3.0.1.1.11.13.9.7SECTION 424.514
   424.514 Application fee.
42:3.0.1.1.11.13.9.8SECTION 424.515
   424.515 Requirements for reporting changes and updates to, and the periodic revalidation of Medicare enrollment information.
42:3.0.1.1.11.13.9.9SECTION 424.516
   424.516 Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.
42:3.0.1.1.11.13.9.10SECTION 424.517
   424.517 Onsite review.
42:3.0.1.1.11.13.9.11SECTION 424.518
   424.518 Screening levels for Medicare providers and suppliers.
42:3.0.1.1.11.13.9.12SECTION 424.519
   424.519 Disclosure of affiliations.
42:3.0.1.1.11.13.9.13SECTION 424.520
   424.520 Effective date of Medicare billing privileges.
42:3.0.1.1.11.13.9.14SECTION 424.521
   424.521 Request for payment by physicians, non-physician practitioners, physician and non-physician organizations, ambulance suppliers, and opioid treatment programs.
42:3.0.1.1.11.13.9.15SECTION 424.525
   424.525 Rejection of a provider or supplier's enrollment application for Medicare enrollment.
42:3.0.1.1.11.13.9.16SECTION 424.530
   424.530 Denial of enrollment in the Medicare program.
42:3.0.1.1.11.13.9.17SECTION 424.535
   424.535 Revocation of enrollment in the Medicare program.
42:3.0.1.1.11.13.9.18SECTION 424.540
   424.540 Deactivation of Medicare billing privileges.
42:3.0.1.1.11.13.9.19SECTION 424.545
   424.545 Provider and supplier appeal rights.
42:3.0.1.1.11.13.9.20SECTION 424.550
   424.550 Prohibitions on the sale or transfer of billing privileges.
42:3.0.1.1.11.13.9.21SECTION 424.555
   424.555 Payment liability.
42:3.0.1.1.11.13.9.22SECTION 424.565
   424.565 Overpayment.
42:3.0.1.1.11.13.9.23SECTION 424.570
   424.570 Moratoria on newly enrolling Medicare providers and suppliers.