[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR405.440]



[Page 105]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 405_FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED--Table of 

Contents

 

                       Subpart D_Private Contracts

 

Sec. 405.440  Emergency and urgent care services.



    (a) A physician or practitioner who has opted-out of Medicare under 

this subpart need not enter into a private contract to furnish emergency 

care services or urgent care services to a Medicare beneficiary. 

Accordingly, a physician or practitioner will not be determined to have 

failed to maintain opt-out if he or she furnishes emergency care 

services or urgent care services to a Medicare beneficiary with whom the 

physician or practitioner has not previously entered into a private 

contract, provided the physician or practitioner complies with the 

billing requirements specified in paragraph (b) of this section.

    (b) When a physician or practitioner who has not been excluded under 

sections 1128, 1156, or 1892 of the Social Security Act furnishes 

emergency care services or urgent care services to a Medicare 

beneficiary with whom the physician or practitioner has not previously 

entered into a private contract, he or she:

    (1) Must submit a claim to Medicare in accordance with both 42 CFR 

part 424 and Medicare instructions (including but not limited to 

complying with proper coding of emergency or urgent care services 

furnished by physicians and practitioners who have opted-out of 

Medicare).

    (2) May collect no more than--

    (i) The Medicare limiting charge, in the case of a physician; or

    (ii) The deductible and coinsurance, in the case of a practitioner.

    (c) Emergency care services or urgent care services furnished to a 

Medicare beneficiary with whom the physician or practitioner has 

previously entered into a private contract (that is, entered into before 

the onset of the emergency medical condition or urgent medical 

condition), are furnished under the terms of the private contract.

    (d) Medicare may make payment for emergency care services or urgent 

care services furnished by a physician or practitioner who has properly 

opted-out when the services are furnished and the claim for services is 

made in accordance with this section. A physician or practitioner who 

has been excluded must comply with the regulations at Sec. 1001.1901 

(Scope and effect of exclusion) of this title when he or she furnishes 

emergency services to beneficiaries and may not bill and be paid for 

urgent care services.