C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 410—SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS › Subpart B—Medical and Other Health Services

42 C.F.R. § 410.42

Limitations on coverage of certain services furnished to hospital outpatients

Read at: eCFRecfr.gov CornellLII GovInfogovinfo.gov CasesGoogle Scholar

(a) General rule. Except as provided in paragraph (b) of this section, Medicare Part B does not pay for any item or service that is furnished to a hospital outpatient (as defined in § 410.2) during an encounter (as defined in § 410.2) by an entity other than the hospital unless the hospital has an arrangement (as defined in § 409.3 of this chapter) with that entity to furnish that particular service to its patients. As used in this paragraph, the term “hospital” includes a CAH.

(b) Exception. The limitations stated in paragraph (a) of this section do not apply to the following services:

(1) Physician services that meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis.

(2) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act.

(3) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act.

(4) Certified nurse mid-wife services, as defined in section 1861(gg) of the Act.

(5) Qualified psychologist services, as defined in section 1861(ii) of the Act.

(6) Services of an anesthetist, as defined in § 410.69.

(7) Services furnished to SNF residents as defined in § 411.15(p) of this chapter.

[65 FR 18536, Apr. 7, 2000]
Notes of Decisions
Cited in 2 cases, 2002–2015 · leading case: Council For Urological Interes v. Sylvia Mathews Burwell, 790 F.3d 212 (D.C. Cir. 2015).
Sort: Relevance Newest Treatment
Council For Urological Interes v. Sylvia Mathews Burwell, 790 F.3d 212 (D.C. Cir. 2015). · cites it 2× “§ 1395x(w)(1); 42 C.F.R. § 410.42 (a). Under these agreements, the third party provides equipment and technicians for a procedure while the hospital provides space and support services, pays for the lease of the equipment, and bills Medicare.”
Long Island Ambulance, Inc. v. Thompson, 220 F. Supp. 2d 150 (E.D.N.Y 2002). “” 42 C.F.R. § 410.42 (c)(2). Medicare regulations authorize the suspension of payments to a provider such as LIA when “the intermediary, or the carrier possesses reliable information that an overpayment or fraud or willful misrepresentation exists.”
Annotations are extracted automatically from the opinions in the Syfert caselaw corpus and ranked by authority, recency, and treatment. Dots show Syfertize treatment of the citing case itself.