[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: 42CFR411.32]



[Page 388-389]

 

                         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. 411.32  Basis for Medicare secondary payments.



    (a) Basic rules. (1) Medicare benefits are secondary to benefits 

payable by a third party payer even if State law or the third party 

payer states that its benefits are secondary to Medicare benefits or 

otherwise limits its payments to Medicare beneficiaries.

    (2) Except as provided in paragraph (b) of this section, Medicare 

makes secondary payments, within the limits specified in paragraph (c) 

of this section and in Sec. 411.33, to supplement the third party 

payment if that payment is less than the charges for the services and, 

in the case of services paid on other than a reasonable charge basis, 

less than the gross amount payable by Medicare under Sec. 411.33(e).



[[Page 389]]



    (b) Exception. Medicare does not make a secondary payment if the 

provider or supplier is either obligated to accept, or voluntarily 

accepts, as full payment, a third party payment that is less than its 

charges.

    (c) General limitation: Failure to file a proper claim. When a 

provider or supplier, or a beneficiary who is not physically or mentally 

incapacitated, receives a reduced third party payment because of failure 

to file a proper claim, the Medicare secondary payment may not exceed 

the amount that would have been payable under Sec. 411.33 if the third 

party payer had paid on the basis of a proper claim.



The provider, supplier, or beneficiary must inform CMS that a reduced 

payment was made, and the amount that would have been paid if a proper 

claim had been filed.