[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR411.54]

[Page 317]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT--Table of Contents
 
 Subpart D--Limitations on Medicare Payment for Services Covered Under 
                     Liability or No-Fault Insurance
 
Sec. 411.54  Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.

    (a) Definition. As used in this section, Medicare-covered services 
means services for which Medicare benefits are payable or would be 
payable except for applicable Medicare deductible and coinsurance 
provisions. Medicare benefits are payable notwithstanding potential 
liability insurance payments, but are recoverable in accordance with 
Sec. 411.24.
    (b) Applicability. This section applies when a beneficiary has 
received a liability insurance payment or has a claim pending against a 
liability insurer for injuries or illness allegedly caused by another 
party.
    (c) Basic rules--(1) Itemized bill. A hospital must, upon request, 
furnish to the beneficiary or his or her representative an itemized bill 
of the hospital's charges.
    (2) Specific limitations. Except as provided in paragraph (d) of 
this section, the provider or supplier--
    (i) May not bill the liability insurer nor place a lien against the 
beneficiary's liability insurance settlement for Medicare covered 
services.
    (ii) May only bill Medicare for Medicare-covered services; and
    (iii) May bill the beneficiary only for applicable Medicare 
deductible and coinsurance amounts plus the amount of any charges that 
may be made to a beneficiary under Sec. 413.35 of this chapter (when 
cost limits are applied to the services) or under Sec. 489.32 of this 
chapter (when services are partially covered).
    (d) Exceptions--(1) Nonparticipating suppliers. The limitations of 
paragraph (c)(2) of this section do not apply if the services were 
furnished by a supplier that is not a participating supplier and has not 
accepted assignment for the services or has not claimed payment for them 
under Sec. 424.64 of this chapter.
    (2) Prepaid health plans. If the services were furnished through an 
organization that has a contract under section 1876 of the Act (that is, 
through an HMO or CMP), or through an organization that is paid under 
section 1833(a)(1)(A) of the Act (that is, through an HCPP) the rules of 
Sec. 417.528 of this chapter apply.
    (3) Special rules for Oregon. For the State of Oregon, because of a 
court decision, and in the absence of a reversal on appeal or a 
statutory clarification overturning the decision, there are the 
following special rules:
    (i) The limitations of paragraph (c)(2) of this section do not apply 
if the liability insurer pays within 120 days after the earlier of the 
following dates:
    (A) The date the hospital files a claim with the insurer or places a 
lien against a potential liability settlement.
    (B) The date the services were provided or, in the case of inpatient 
hospital services, the date of discharge.
    (ii) If the liability insurer does not pay within the 120-day 
period, the hospital must withdraw its claim or lien and comply with the 
limitations imposed by paragraph (c)(2) of this section.