[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: 42CFR405.506]



[Page 116-117]

 

                         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. 405.506  Charges higher than customary or prevailing charges or 

lowest charge levels.



    A charge which exceeds the customary charge of the physician or 

other person who rendered the medical or other health service, or the 

prevailing charge in the locality, or an applicable lowest charge level 

may be found to be reasonable, but only where there are unusual 

circumstances, or medical complications requiring additional time, 

effort or expense which support an additional charge, and only if it is 

acceptable medical or medical service practice in the locality to make 

an extra charge in such cases. The



[[Page 117]]



mere fact that the physician's or other person's customary charge is 

higher than prevailing would not justify a determination that it is 

reasonable.



(Secs. 1102, 1842(b) and 1871, 1903(i)(1) of the Social Security Act; 49 

Stat. 647, 79 Stat. 302, 310, 331; 86 Stat. 1395, 1454; (42 U.S.C. 1302, 

1395u(b), 1395hh, 1396b(i)(1)))



[43 FR 32300, July 26, 1978]