42 C.F.R. § 421.3
Definitions
As used in this part—
Intermediary means an entity that has a contract with CMS (under statutory provisions in effect prior to October 1, 2005) to determine and make Medicare payments for Part A or Part B benefits payable on a cost basis (or under the prospective payment system for hospitals) and to perform other related functions. For purposes of applying the performance criteria in § 421.120 and the performance standards in § 421.122 and any adverse action resulting from that application, the term “intermediary” also means a Blue Cross plan that has entered into a subcontract approved by CMS with the Blue Cross and Blue Shield Association to perform intermediary functions.
Notes of Decisions
Cited in 18
cases (1 in the last 5 years), 1985–2026 · leading case: Hays Med. Ctr. v. Azar, 956 F.3d 1247 (10th Cir. 2020).
Hays Med. Ctr. v. Azar, 956 F.3d 1247 (10th Cir. 2020). “§ 1395h; 42 C.F.R. §§ 421.3 , 421.100. As relevant here, reimbursement of participating hospitals’ Medicare Part A costs is sought and made through these intermediaries, and as part of that process, the intermediaries are responsible for actually performing the reimbursement…”
Baptist Mem'l Hosp. v. Johnson, 603 F. Supp. 2d 40 (D.D.C. 2009). “See 42 C.F.R. § 421.3 ; In re Medicare Reimbursement Litigation, 414 F.”
United States ex rel. Colquitt v. Abbott Labs., 864 F. Supp. 2d 499 (N.D. Tex. 2012). “§ 1395h; 42 C.F.R. §§ 421.3 , 421.100. These contractors review claims to determine whether they are appropriate for reimbursement under *531 Medicare.”
United States ex rel. Reagan v. East Texas Med. Ctr. Reg'l Healthcare Sys., 384 F.3d 168 (5th Cir. 2004). “§ 1395h, 42 C.F.R. §§ 421.3 , 421.100-421.128. The fiscal intermediaiy will make payments to the provider throughout the year based upon projections of the provider's allowable Medicare related expenses.”
Grp. Health Inc. v. Blue Cross Ass'n, 739 F. Supp. 921 (S.D.N.Y. 1990). “See 42 C.F.R. § 421.3 (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.”
Yale-New Haven Hosp., Inc. v. Thompson, 162 F. Supp. 2d 54 (D. Conn. 2001). “§ 1395h; 42 C.F.R. §§ 421.3 , 421.100, 424.33; see Cedars-Sinai, 939 F.”
C. Jack Friedman, Ph.D. & Assocs., P.C. v. Pennsylvania Blue Shield, 836 F. Supp. 263 (E.D. Pa. 1993). “§ 1395u(f); 42 C.F.R. § 421.3 . Moreover, in any litigation involving the administration of the Medicare program by a carrier, the HCFA is the real parly in interest.”
Fac, Inc. v. Cooperativa De Seguros De Vida, 106 F. Supp. 2d 244 (D.P.R. 2000). “; 42 C.F.R. §§ 421.3 , 421.100(a) (1999). In deciding whether to reimburse Medicare claims, fiscal intermediaries must consider whether the services furnished were reasonable, medically necessary, and furnished in the most appropriate setting.”
Homewood Prof'l Care Ctr., Ltd. v. Heckler, 764 F.2d 1242 (7th Cir. 1985). “§ 1395h; 42 C.F.R. § 421.3 . "The intermediary must assure that it makes payments only for services that are: (1) Furnished to Medicare beneficiaries; (2) Covered under Medicare part A or part B; and (3) Medically necessary.”
Jagow v. Mut. of Omaha Ins. Co., 392 F. App'x 618 (10th Cir. 2010). “Part 421, Subpart B; 42 C.F.R. § 421.3 . Intermediaries implemented the payment schemes mandated by the Medicare Act and regulations.”
St. Agnes Med. Ctr. v. Sebelius, 628 F. Supp. 2d 78 (D.D.C. 2009). “See 42 C.F.R. § 421.3 ; In re Medicare Reimbursement Litigation, 414 F.”
United States v. Seibert, 403 F. Supp. 2d 904 (S.D. Iowa 2005). “§ 1395h; 42 C.F.R. §§ 421.3 , 100 (1995). 3 Fiscal intermediaries reimburse providers for the cost of services incurred on behalf of Medicare beneficiaries.”
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