[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: 42CFR405.501]



[Page 107]

 

                         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 E_Criteria for Determining Reasonable Charges

 

Sec. 405.501  Determination of reasonable charges.



    (a) Except as specified in paragraphs (b), (c), and (d) of this 

section, Medicare pays no more for Part B medical and other health 

services than the ``reasonable charge'' for such service. The reasonable 

charge is determined by the carriers (subject to any deductible and 

coinsurance amounts as specified in Sec. Sec. 410.152 and 410.160 of 

this chapter).

    (b) Part B of Medicare pays on the basis of ``reasonable cost'' (see 

part 413 of this chapter) for certain institutional services, certain 

services furnished under arrangements with institutions, and services 

furnished by entities that elect to be paid on a cost basis (including 

health maintenance organizations, rural health clinics, Federally 

qualified health centers and end-stage renal disease facilities).

    (c) Carriers will determine the reasonable charge on the basis of 

the criteria specified in Sec. 405.502, and the customary and 

prevailing charge screens in effect when the service was furnished. 

(Also see Sec. Sec. 415.55 through 415.70 and Sec. Sec. 415.100 

through 415.130 of this chapter, which pertain to the determination of 

reimbursement for services performed by hospital-based physicians.) 

However, when services are furnished more than 12 months before the 

beginning of the fee screen year (January 1 through December 30) in 

which a request for payment is made, payment is based on the customary 

and prevailing charge screens in effect for the fee screen year that 

ends immediately preceding the fee screen year in which the claim or 

request for payment is made.

    (d) Payment under Medicare Part B for durable medical equipment and 

prosthetic and orthotic devices is determined in accordance with the 

provisions of subpart D of part 414 of this chapter.



[47 FR 63274, Dec. 31, 1981, as amended at 51 FR 34978, Oct. 1, 1986; 51 

FR 37911, Oct. 27, 1986; 54 FR 9003, Mar. 2, 1989; 57 FR 24975, June 12, 

1992; 57 FR 33896, July 31, 1992; 57 FR 57688, Dec. 7, 1992; 60 FR 

63176, Dec. 8, 1995]