C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 421—MEDICARE CONTRACTING › Subpart B—Intermediaries

42 C.F.R. § 421.100

Intermediary functions

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

An agreement between CMS and an intermediary specifies the functions to be performed by the intermediary.

(a) Mandatory functions. The contract must include the following functions:

(1) Determining the amount of payments to be made to providers for covered services furnished to Medicare beneficiaries.

(2) Making the payments.

(b) Additional functions. The contract may include any or all of the following functions:

(1) Any or all of the program integrity functions described in § 421.304, provided the intermediary is continuing those functions under an agreement entered into under section 1816 of the Act that was in effect on August 21, 1996, and they do not duplicate work being performed under a Medicare integrity program contract.

(2) Undertaking to adjust incorrect payments and recover overpayments when it is determined that an overpayment was made.

(3) Furnishing to CMS timely information and reports that CMS requests in order to carry out its responsibilities in the administration of the Medicare program.

(4) Establishing and maintaining procedures as approved by CMS for the redetermination of payment determinations.

(5) Maintaining records and making available to CMS the records necessary for verification of payments and for other related purposes.

(6) Upon inquiry, assisting individuals for matters pertaining to an intermediary agreement.

(7) Serving as a channel of communication to and from CMS of information, instructions, and other material as necessary for the effective and efficient performance of an intermediary agreement.

(8) Undertaking other functions as mutually agreed to by CMS and the intermediary.

(c) Dual intermediary responsibilities. Regarding the responsibility for service to provider-based HHAs and provider-based hospices, where the HHA or the hospice and its parent provider will be served by different intermediaries, the designated regional intermediary will process bills, make coverage determinations, and make payments to the HHAs and the hospices. The intermediary or Medicare integrity program contractor serving the parent provider will perform all fiscal functions, including audits and settlement of the Medicare cost reports and the HHA and hospice supplement worksheets.

[72 FR 48886, Aug. 24, 2007]
Notes of Decisions
Cited in 41 cases (4 in the last 5 years), 1983–2026 · leading case: Maine Med. Ctr. v. Burwell, 841 F.3d 10 (1st Cir. 2016).
Sort: Relevance Newest Treatment
Maine Med. Ctr. v. Burwell, 841 F.3d 10 (1st Cir. 2016). · cites it 2× “See 42 C.F.R. § 421.100 . 2 Initially, the federal government reimbursed hospitals for the “reasonable cost” of treating Medicáis patients.”
Bethesda Hosp. Assn. v. Bowen, 485 U.S. 399 (1988). “120 (directing that the Secretary shall periodically review an intermediary’s *405 audit procedures to ensure it is making “[e]orrect coverage and payment determinations” and is guarding the “proper management of administrative funds”); 42 CFR § 405.”
Nichole Med. Equip. & Supply, Inc. v. Tricenturion, Inc., 694 F.3d 340 (3rd Cir. 2012). “42 C.F.R. §§ 421.100 , 421.200; see also 30 Fed.”
In re Cardiac Devices Qui Tam Litig., 221 F.R.D. 318 (D. Conn. 2004). “§ 1395h(a); 42 C.F.R. § 421.100 (a). In making these determinations, the fiscal intermediaries are bound to follow the instructions promulgated by the Secretary.”
Mercy Home Health v. Michael O. Leavitt, Sec'y of Health & Human Servs., 436 F.3d 370 (3rd Cir. 2006). “§§ 1395h, 1395kk-l; 42 C.F.R. § 421.100 . Congress authorized the Secretary “to promulgate regulations ‘establishing the method or methods to be used’ for determining reasonable costs.”
Hays Med. Ctr. v. Azar, 956 F.3d 1247 (10th Cir. 2020). “See 42 C.F.R. § 421.100 . 20 the intermediaries were to apply a cumulative budget-neutrality adjustment to the hospital-specific rate for the new base year.”
Sentara-Hampton Gen. Hosp. v. Louis v. Sullivan, M.D., Sec'y of Health & Human Servs., 980 F.2d 749 (D.C. Cir. 1992). “§ 1395h; 42 C.F.R. § 421.100 . Under the cost reimbursement system, the intermediary distributes to providers estimated payments during a cost reporting year.”
United States Ex Rel. Sarasola v. Aetna Life Ins., 319 F.3d 1292 (11th Cir. 2003). · cites it 2× “42 C.F.R. § 421.100 (c); see also 42 U.S.”
Pines Residential Treatment Ctr., Inc. v. United States, 64 Fed. Cl. 307 (Fed. Cl. 2005). · cites it 2× “42 C.F.R. § 421.100 (2004). Intermediaries review yearly cost reports to “determinen the amount due, or owed by, [providers] for the period” and must “offset any underpayment determined for the period against any overpayment identified for a prior period.”
Schwartz v. Medicare, 832 F. Supp. 782 (D.N.J. 1993). · cites it 2× “§§ 1395h, 1395kk(b); 42 C.F.R. §§ 421.100 , 421.200; see also Neurological Assocs.”
Grp. Health Inc. v. Blue Cross Ass'n, 739 F. Supp. 921 (S.D.N.Y. 1990). · cites it 2× “3 (1989) (“ ‘[intermediary’ means an entity that has a contract with HCFA to determine and make Medicare payments for Part A or Part B benefits payable on a cost basis and to perform other related functions”) and 42 C.F.R. § 421.100 (1989) (non-exhaustive list of functions…”
State of NY v. Lutheran Ctr. for the Aging, Inc., 957 F. Supp. 393 (E.D.N.Y 1997). “§ 1395h; 42 C.F.R. §§ 421.100 (a), 421.103, 421.200(a).”
Show all 41 citing cases →
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.