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 C—Carriers

42 C.F.R. § 421.200

Carrier functions

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A contract between CMS and a carrier specifies the functions to be performed by the carrier. The contract may include any or all of the following functions:

(a) Any or all of the program integrity functions described in § 421.304 provided the following conditions are met:

(1) The carrier is continuing those functions under a contract entered into under section 1842 of the Act that was in effect on August 21, 1996.

(2) The functions do not duplicate work being performed under a Medicare integrity program contract, except that the function related to developing and maintaining a list of DME may be performed under both a carrier contract and a Medicare integrity program contract.

(b) Receiving, disbursing, and accounting for funds in making payments for services furnished to eligible individuals within the jurisdiction of the carrier.

(c) Determining the amount of payment for services furnished to an eligible individual.

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

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

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

(g) Establishing and maintaining procedures under which an individual enrolled under Part B is granted an opportunity for a redetermination.

(h) Upon inquiry, assisting individuals with matters pertaining to a carrier contract.

(i) 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 a carrier contract.

(j) Undertaking other functions as mutually agreed to by CMS and the carrier.

[72 FR 48886, Aug. 24, 2007]
Notes of Decisions
Cited in 33 cases (3 in the last 5 years), 1982–2026 · leading case: Kailash C. Pani, M.D., & Kailash C. Pani, M.D., P.C. v. Empire Blue Cross Blue Shield, 152 F.3d 67 (2d Cir. 1998).
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Kailash C. Pani, M.D., & Kailash C. Pani, M.D., P.C. v. Empire Blue Cross Blue Shield, 152 F.3d 67 (2d Cir. 1998). · cites it 2× “371 (b) (authorizing carriers to suspend payments under circumstances involving fraud or willful misrepresentation); 42 C.F.R. § 421.200 (nonexhaustive list of carrier responsibilities); Bodimetric Health Servs.”
Randall D. Wolcott, Md, Pa v. Sebelius, 635 F.3d 757 (5th Cir. 2011). “42 C.F.R. § 421.200 . TrailBlazer is acting as the Medicare carrier for Wolcott.”
United States of Am., Cross-Appellee v. John Canova, 412 F.3d 331 (2d Cir. 2005). “§ 1395u; 42 C.F.R. § 421.200 (providing non-exclusive list of carrier functions, including provider audits); see generally Pani v.”
Schweiker v. McClure, 456 U.S. 188 (1982). “IV); 42 CFR §§ 421.200 , 421.202, and 421.205(a) (1980).”
Gulfcoast Med. Supply, Inc. v. Sec'y, Dep't of Health & Human Servs., 468 F.3d 1347 (11th Cir. 2006). · cites it 2× “§ 1395u; 42 C.F.R. § 421.200 (a)(2). When the carrier discovers that an overpayment has occurred, the carrier may suspend or recoup payment.”
Power Mobility Coalition v. Leavitt, 404 F. Supp. 2d 190 (D.D.C. 2005). “, 42 C.F.R. § 421.200 . Id. at 4 . DMER carriers process claims for DME (including PMDs) payments within designated regions of the country.”
United States v. Cabrera-Diaz, 106 F. Supp. 2d 234 (D.P.R. 2000). · cites it 2× “42 C.F.R. § 421.200 . Under the authority of 42 U.”
Florida Med. Ctr. of Clearwater, Inc. v. Sebelius, 614 F.3d 1276 (11th Cir. 2010). “§ 1395u; 42 C.F.R. § 421.200 (a)(2). If the carrier discovers that an overpayment has occurred, the carrier may suspend or recoup payment.”
Medicare&medicaid Gu 34,507 Richard D. Bushman v. Joseph E. Seiler, 755 F.2d 653 (8th Cir. 1985). “See generally 42 C.F.R. § 421.200 (1983) (functions of Medicare carriers).”
Smith v. Burwell, 209 F. Supp. 3d 98 (D.D.C. 2016). “§ 1395u; 42 C.F.R. § 421.200 . Medicare Part B is one of the program’s four segments.”
Marsaw v. Trailblazer Health Enter., L.L.C., 192 F. Supp. 2d 737 (S.D. Tex. 2002). “See 42 C.F.R. § 421.200 . In the instant case, Defendant Trailblazer was the private insurance company acting as the Part B Medicare carrier for Plaintiffs’ seven Texas facilities.”
Almy v. Sebelius, 749 F. Supp. 2d 315 (D. Maryland 2010). “§ 1395u; 42 C.F.R. § 421.200 . Each of the four geographic jurisdictions created by the Centers for Medicare and Medicaid Services (“CMS”) has its own DMAC.”
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