[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: 42CFR411.54]



[Page 395-396]

 

                         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 D_Limitations on Medicare Payment for Services Covered Under 

                     Liability or No-Fault Insurance

 

Sec. 411.54  Limitation on charges when a beneficiary has received a 

liability insurance payment or has a claim pending against a liability 

insurer.



    (a) Definition. As used in this section, Medicare-covered services 

means services for which Medicare benefits are payable or would be 

payable except for applicable Medicare deductible and coinsurance 

provisions. Medicare benefits are payable notwithstanding potential 

liability insurance payments, but are recoverable in accordance with 

Sec. 411.24.

    (b) Applicability. This section applies when a beneficiary has 

received a liability insurance payment or has a claim pending against a 

liability insurer for injuries or illness allegedly caused by another 

party.

    (c) Itemized bill. A hospital must, upon request, furnish to the 

beneficiary or his or her representative an itemized bill of the 

hospital's charges.

    (d) Exception--(1) Prepaid health plans. If the services were 

furnished through an organization that has a contact under section 1876 

of the Act (that is, an HMO or CMP), or through an organization that is 

paid under section 1833(a)(1)(A) of the Act (that is, through an HCPP) 

the rules of Sec. 417.528 of this chapter apply.

    (2) Special rules for Oregon. For the State of Oregon, because of a 

court decision, and in the absence of a reversal on appeal or a 

statutory clarification overturning the decision, there are the 

following special rules:

    (i) The provider or supplier may elect to bill a liability insurer 

or place a lien against the beneficiary's liability settlement for 

Medicare covered services, rather than bill only Medicare for Medicare 

covered services, if the liability insurer pays within 120 days after 

the earlier of the following dates:

    (A) The date the provider or supplier files a claim with the insurer 

or places a lien against a potential liability settlement.



[[Page 396]]



    (B) The date the services were provided or, in the case of inpatient 

hospital services, the date of discharge.

    (ii) If the liability insurer does not pay within the 120-day 

period, the provider or supplier:

    (A) Must withdraw its claim with the liability insurer and/or 

withdraw its lien against a potential liability settlement.

    (B) May only bill Medicare for Medicare covered services.

    (C) May bill the beneficiary only for applicable Medicare deductible 

and co-insurance amounts plus the amount of any charges that may be made 

to a beneficiary under 413.35 of this chapter (when cost limits are 

applied to these services) or under 489.32 of this chapter (when 

services are partially covered).



[54 FR 41734, Oct. 11, 1989, as amended at 68 FR 43942, July 25, 2003]