C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 411—EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT › Subpart D—Limitations on Medicare Payment for Services Covered Under Liability or No-Fault Insurance

42 C.F.R. § 411.52

Basis for conditional Medicare payment in liability cases

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(a) A conditional Medicare payment may be made in liability cases under either of the following circumstances:

(1) The beneficiary has filed a proper claim for liability insurance benefits but the intermediary or carrier determines that the liability insurer will not pay promptly for any reason other than the circumstances described in § 411.32(a)(1). This includes cases in which the liability insurance carrier has denied the claim.

(2) The beneficiary has not filed a claim for liability insurance benefits.

(b) Any conditional payment that CMS makes is conditioned on reimbursement to CMS in accordance with subpart B of this part.

[71 FR 9470, Feb. 24, 2006]
Notes of Decisions
Cited in 7 cases, 1996–2019 · leading case: Wainscott v. Centura Health Corp., 351 P.3d 513 (Colo. Ct. App. 2014).
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Wainscott v. Centura Health Corp., 351 P.3d 513 (Colo. Ct. App. 2014). “$ 1895y(b)@)(B)G); 42 CFR. § 411.52(a)(1) (2018). "Promptly" is *528 defined as within 120 days of the earlier of (1) the date a hospital lien is filed or (2) the date the patient is discharged from the hospital 42 CER.”
Stalley Ex Rel. United States v. Catholic Health Initiatives, 458 F. Supp. 2d 958 (E.D. Ark. 2006). “See also 42 C.F.R. § 411.52 (a). Plaintiff seeks to bring his claim under the above MSP provision.”
Share Health Plan of Illinois, Inc. v. Alderson, 674 N.E.2d 69 (Ill. App. Ct. 1996). “42 C.F.R. §§ 411.52 , 411.21 (1996). The general provisions of the current Code provide that where a conditional payment is made and the beneficiary recovers from the primary payer, the HCFA may recover the "lesser of the *** amount of the Medicare primary payment *** [or] the…”
McKim v. S. Illinois Hosp. Servs., 2016 IL App (5th) 140405 (Ill. App. Ct. 2016). “§ 1395y(b)(2)(B)(i) (2012); 42 C.F.R. § 411.52 (2012). Medicare has a direct right to recover the entire amount of the bills paid from the entity responsible to make the primary payment, or alternatively from the individual or entity that received payment from the responsible…”
McKim v. S. Illinois Hosp. Servs., 2016 IL App (5th) 140405 (Ill. App. Ct. 2016). “§ 1395y(b)(2)(B)(i) (2012); 42 C.F.R. § 411.52 (2012). Medicare has a direct right to recover the entire amount of the bills paid from the entity responsible to make the primary payment, or alternatively from the individual or entity that received payment from the responsible…”
Cox Ex Rel. Est. of Cox v. Shalala, 112 F.3d 151 (4th Cir. 1997). “§ 1395y(b)(2)(B)(i); 42 C.F.R. § 411.52 (1993). When such a conditional payment is made for medical care, the government has a direct right of recovery for the entire amount conditionally paid from any entity responsible for making primary payment.”
MSP Recovery Claims, Series LLC v. Plymouth Rock Assurance Corp., Inc. (D. Mass. 2019). “See 42 C.F.R. § 411.52 (b). The Third Circuit reasoned that because “subchapter” as used in § 1395y(b)(2)(A) refers to the Medicare Act as a whole, § 1395y(b)(3)(A) allows an action by an MAO where it has been damaged by a primary payer’s failure to reimburse it for conditional…”
— 42 C.F.R. § 411.52(a)(1) — 1 case
Wainscott v. Centura Health Corp., 351 P.3d 513 (Colo. Ct. App. 2014). “$ 1895y(b)@)(B)G); 42 CFR. § 411.52(a)(1) (2018). "Promptly" is *528 defined as within 120 days of the earlier of (1) the date a hospital lien is filed or (2) the date the patient is discharged from the hospital 42 CER.”
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