[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: 42CFR411.21]



[Page 385-386]

 

                         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 B_Insurance Coverage That Limits Medicare Payment: General 

                               Provisions

 

Sec. 411.21  Definitions.



    In this subpart B and in subparts C through H of this part, unless 

the context indicates otherwise--

    Conditional payment means a Medicare payment for services for which 

another payer is responsible, made either on the bases set forth in 

subparts C through H of this part, or because the intermediary or 

carrier did not know that the other coverage existed.

    Coverage or covered services, when used in connection with third 

party payments, means services for which a



[[Page 386]]



third party payer would pay if a proper claim were filed.

    Monthly capitation payment means a comprehensive monthly payment 

that covers all physician services associated with the continuing 

medical management of a maintenance dialysis patient who dialyses at 

home or as an outpatient in an approved ESRD facility.

    Plan means any arrangement, oral or written, by one or more 

entities, to provide health benefits or medical care or assume legal 

liability for injury or illness.

    Prompt or promptly, when used in connection with third party 

payments, except as provided in Sec. 411.50, for payments by liability 

insurers, means payment within 120 days after receipt of the claim.

    Proper claim means a claim that is filed timely and meets all other 

claim filing requirements specified by the plan, program, or insurer.

    Secondary, when used to characterize Medicare benefits, means that 

those benefits are payable only to the extent that payment has not been 

made and cannot reasonably be expected to be made under other coverage 

that is primary to Medicare.

    Secondary payments means payments made for Medicare covered services 

or portions of services that are not payable under other coverage that 

is primary to Medicare.

    Third party payer means an insurance policy, plan, or program that 

is primary to Medicare.

    Third party payment means payment by a third party payer for 

services that are also covered under Medicare.



[54 FR 41734, Oct. 11, 1989, as amended at 60 FR 45361, Aug. 31, 1995]