[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: 42CFR411.112]



[Page 401]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 411_EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

--Table of Contents

 

Subpart E_Limitations on Payment for Services Covered Under Group Health 

                        Plans: General Provisions

 

Sec. 411.112  Documentation of conformance.



    (a) Acceptable documentation. CMS may require a GHP or LGHP to 

demonstrate that it has complied with the Medicare secondary payer 

provisions and to submit supporting documentation by an official 

authorized to act on behalf of the entity, under penalty of perjury. The 

following are examples of documentation that may be acceptable:

    (1) A copy of the employer's plan or policy that specifies the 

services covered, conditions of coverage, benefit levels and limitations 

with respect to persons entitled to Medicare on the basis of ESRD, age, 

or disability as compared to the provisions applicable to other 

enrollees and potential enrollees.

    (2) An explanation of the plan's allegation that it does not owe CMS 

any amount CMS claims the plan owes as repayment for conditional or 

mistaken Medicare primary payments.

    (b) Lack of acceptable documentation. If a GHP or LGHP fails to 

provide acceptable evidence or documentation that it has complied with 

the MSP prohibitions and requirements set forth in Sec. 411.110, CMS 

may make a determination of nonconformance for both the year in which 

the services were furnished and the year in which the request for 

information was made.