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. § 411.53

Basis for conditional Medicare payment in no-fault cases

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(a) A conditional Medicare payment may be made in no-fault cases under either of the following circumstances:

(1) The beneficiary has filed a proper claim for no-fault insurance benefits but the intermediary or carrier determines that the no-fault insurer will not pay promptly for any reason other than the circumstances described in § 411.32(a)(1). This includes cases in which the no-fault insurance carrier has denied the claim.

(2) The beneficiary, because of physical or mental incapacity, failed to meet a claim-filing requirement stipulated in the policy.

(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 2 cases (2 in the last 5 years), 2021–2026 · leading case: Lynette Duncan v. Liberty Mut. Ins. Co. (6th Cir. 2021).
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Lynette Duncan v. Liberty Mut. Ins. Co. (6th Cir. 2021). “42 C.F.R. § 411.53 . Further, 42 C.F.R. § 411.”
MSP Recovery Claims, Series LLC, a Delaware Ltd. Liab. Co.; & Series 16-08-483, a designated series of MSP Recovery Claims, Series, LLC v. Merchants Mut. Ins. Co., a Delaware Corp.; Merchants Nat'l Ins. Co., a New Hampshire Corp.; & Merchants Preferred Ins. Co., a Delaware Corp. (W.D.N.Y. 2026). “” Similarly, 42 C.F.R. §411.53 , entitled “Basis for conditional Medicare payment in no-fault cases”, provides: “(a) A conditional Medicare payment may be made in no-fault cases under either of the following circumstances: (1) The beneficiary has filed a proper claim for…”
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