[Code of Federal Regulations] [Title 42, Volume 3] [Revised as of October 1, 2004] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR489.20] [Page 937-939] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PART 489_PROVIDER AGREEMENTS AND SUPPLIER APPROVAL--Table of Contents Subpart B_Essentials of Provider Agreements Sec. 489.20 Basic commitments. The provider agrees to the following: (a) To limit its charges to beneficiaries and to other individuals on their behalf, in accordance with provisions of subpart C of this part. (b) To comply with the requirements of subpart D of this part for the return or other disposition of any amounts incorrectly collected from a beneficiary or any other person in his or her behalf. (c) To comply with the requirements of Sec. 420.203 of this chapter when it hires certain former employees of intermediaries. (d) In the case of a hospital or a CAH that furnishes services to Medicare beneficiaries, either to furnish directly or to make arrangements (as defined in Sec. 409.3 of this chapter) for all Medicare-covered services to inpatients and outpatients of a hospital or a CAH except the following: (1) Physicians' services that meet the criteria of Sec. 415.102(a) of this chapter for payment on a reasonable charge basis. (2) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act, that are furnished after December 31, 1990. (3) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (4) Certified nurse-midwife services, as defined in section 1861(ff) of the Act, that are furnished after December 31, 1990. (5) Qualified psychologist services, as defined in section 1861(ii) of the Act, that are furnished after December 31, 1990. (6) Services of an anesthetist, as defined in Sec. 410.69 of this chapter. (e) In the case of a hospital or CAH that furnishes inpatient hospital services or inpatient CAH services for which payment may be made under Medicare, to maintain an agreement with a QIO for that organization to review the admissions, quality, appropriateness, and diagnostic information related to those inpatient services. The requirement of this paragraph (e) applies only if, for the area in which the hospital or CAH is located, there is a QIO that has a contract with CMS under part B of title XI of the Act. (f) To maintain a system that, during the admission process, identifies any primary payers other than Medicare, so that incorrect billing and Medicare overpayments can be prevented. (g) To bill other primary payers before Medicare. (h) If the provider receives payment for the same services from Medicare and another payer that is primary to Medicare, to reimburse Medicare any overpaid amount within 60 days. (i) If the provider receives, from a payer that is primary to Medicare, a payment that is reduced because the provider failed to file a proper claim-- (1) To bill Medicare for an amount no greater than would have been payable as secondary payment if the primary insurer's payment had been based on a proper claim; and (2) To charge the beneficiary only: (i) The amount it would have been entitled to charge if it had filed a proper claim and received payment based on such a claim; and (ii) An amount equal to any third party payment reduction attributable to failure to file a proper claim, but only if the provider can show that-- (A) It failed to file a proper claim solely because the beneficiary, for any reason other than mental or physical incapacity, failed to give the provider the necessary information; or (B) The beneficiary, who was responsible for filing a proper claim, failed to do so for any reason other than mental or physical incapacity. (j) In 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, hospitals may bill liability insurers first. However, if the liability insurer does not pay ``promptly'', as defined in Sec. 411.50 of this chapter, the hospital [[Page 938]] must withdraw its claim or lien and bill Medicare for covered services. (k) In the case of home health agencies that provide home health services to Medicare beneficiaries under subpart E of part 409 and subpart C f part 410 of this chapter, to offer to furnish catheters, catheter supplies, ostomy bags, and supplies related to ostomy care to any individual who requires them as part of their furnishing of home health services. (l) In the case of a hospital as defined in Sec. 489.24(b) to comply with Sec. 489.24. (m) In the case of a hospital as defined in Sec. 489.24(b), to report to CMS or the State survey agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital in violation of the requirements of Sec. 489.24(e). (n) In the case of inpatient hospital services, to participate in any health plan contracted for under 10 U.S.C. 1079 or 1086 or 38 U.S.C. 613, in accordance with Sec. 489.25. (o) In the case of inpatient hospital services, to admit veterans whose admission has been authorized under 38 U.S.C. 603, in accordance with Sec. 489.26. (p) To comply with Sec. 489.27 of this part concerning notification of Medicare beneficiaries of their rights associated with the termination of Medicare services. (q) In the case of a hospital as defined in Sec. 489.24(b)-- (1) To post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area), a sign (in a form specified by the Secretary) specifying rights of individuals under Section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and (2) To post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital participates in the Medicaid program under a State plan approved under title XIX. (r) In the case of a hospital as defined in Sec. 489.24(b) (including both the transferring and receiving hospitals), to maintain-- (1) Medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer; (2) A list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition; and (3) A central log on each individual who comes to the emergency department, as defined in Sec. 489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. (s) In the case of an SNF, either to furnish directly or make arrangements (as defined in Sec. 409.3 of this chapter) for all Medicare-covered services furnished to a resident (as defined in Sec. 411.15(p)(3) of this chapter) of the SNF, except the following: (1) Physicians' services that meet the criteria of Sec. 415.102(a) of this chapter for payment on a fee schedule basis. (2) Services performed under a physician's supervision by a physician assistant who meets the applicable definition in section 1861(aa)(5) of the Act. (3) Services performed by a nurse practitioner or clinical nurse specialist who meets the applicable definition in section 1861(aa)(5) of the Act and is working in collaboration (as defined in section 1861(aa)(6) of the Act) with a physician. (4) Services performed by a certified nurse-midwife, as defined in section 1861(gg) of the Act. (5) Services performed by a qualified psychologist, as defined in section 1861(ii) of the Act. (6) Services performed by a certified registered nurse anesthetist, as defined in section 1861(bb) of the Act. (7) Dialysis services and supplies, as defined in section 1861(s)(2)(F) of the Act, and those ambulance services that are furnished in conjunction with them. [[Page 939]] (8) Erythropoietin (EPO) for dialysis patients, as defined in section 1861(s)(2)(O) of the Act. (9) Hospice care, as defined in section 1861(dd) of the Act. (10) An ambulance trip that initially conveys an individual to the SNF to be admitted as a resident, or that conveys an individual from the SNF in connection with one of the circumstances specified in Sec. 411.15(p)(3)(i) through (p)(3)(iv) of this chapter as ending the individual's status as an SNF resident. (11) The transportation costs of electrocardiogram equipment (HCPCS code R0076), but only with respect to those electrocardiogram test services furnished during 1998. (12) Those chemotherapy items identified, as of July 1, 1999, by HCPCS codes J9000-J9020; J9040-J9151; J9170-J9185; J9200-J9201; J9206- J9208; J9211; J9230-J9245; and J9265-J9600; and, as of January 1, 2004, by HCPCS codes A9522 and A9523. (13) Those chemotherapy administration services identified, as of July 1, 1999, by HCPCS codes 36260-36262; 36489; 36530-36535; 36640; 36823; and 96405-96542. (14) Those radioisotope services identified, as of July 1, 1999, by HCPCS codes 79030-79440. (15) Those customized prosthetic devices (including artificial limbs and their components) identified, as of July 1, 1999, by HCPCS codes L5050-L5340; L5500-L5611; L5613-L5986; L5988; L6050-L6370; L6400-6880; L6920-L7274; and L7362-L7366, which are delivered for a resident's use during a stay in the SNF and intended to be used by the resident after discharge from the SNF. (t) Hospitals that are not otherwise subject to the Occupational Safety and Health Act of 1970 (or a State occupational safety and health plan that is approved under section 18(b) of the Occupational Safety and Health Act) must comply with the bloodborne pathogens (BBP) standards under 29 CFR 1910.1030. A hospital that fails to comply with the BBP standards may be subject to a civil money penalty in accordance with section 17 of the Occupational Safety and Health Act of 1970, including any adjustments of the civil money penalty amounts under the Federal Civil Penalties Inflation Adjustment Act, for a violation of the BBP standards. A civil money penalty will be imposed and collected in the same manner as civil money penalties under section 1128A(a) of the Social Security Act. [45 FR 22937, Apr. 4, 1980, as amended at 48 FR 39837, Sept. 1, 1983; 49 FR 323, Jan. 3, 1984; 54 FR 41747, Oct. 11, 1989; 57 FR 36018, Aug. 12, 1992; 58 FR 30677, May 26, 1993; 59 FR 32120, June 22, 1994; 60 FR 63189, Dec. 8, 1995; 62 FR 46037, Aug. 29, 1997; 63 FR 26312, May 12, 1998; 65 FR 18548, Apr. 7, 2000; 65 FR 46796, July 31, 2000; 66 FR 39601, July 31, 2001; 68 FR 16669, Apr. 4, 2003; 68 FR 43942, July 25, 2003; 68 FR 46072, Aug. 4, 2003; 69 FR 49272, Aug. 11, 2004] Effective Date Note: At 59 FR 32120, June 22, 1994, in Sec. 489.20, paragraphs (l) through (r) were added. Paragraphs (m), (r)(2) and (r)(3) contain information collection and recordkeeping requirements and will not become effective until approval has been given by the Office of Management and Budget.