C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 422—MEDICARE ADVANTAGE PROGRAM › Subpart K—Application Procedures and Contracts for Medicare Advantage Organizations

42 C.F.R. § 422.520

Prompt payment by MA organization

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(a) Contract between CMS and the MA organization. (1) The contract between CMS and the MA organization must provide that the MA organization will pay 95 percent of the “clean claims” within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an MA private fee-for-service plan or are claims for services that are not furnished under a written agreement between the organization and the provider.

(2) The MA organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B).

(3) All other claims from non-contracted providers must be paid or denied within 60 calendar days from the date of the request.

(b)(1) Contracts between MA organizations and providers and suppliers. Contracts or other written agreements between MA organizations and providers must contain a prompt payment provision, the terms of which are developed and agreed to by both the MA organization and the relevant provider.

(2) The MA organization is obligated to pay contracted providers under the terms of the contract between the MA organization and the provider.

(c) Failure to comply. If CMS determines, after giving notice and opportunity for hearing, that an MA organization has failed to make payments in accordance with paragraph (a) of this section, CMS may provide—

(1) For direct payment of the sums owed to providers, or MA private fee-for-service plan enrollees; and

(2) For appropriate reduction in the amounts that would otherwise be paid to the organization, to reflect the amounts of the direct payments and the cost of making those payments.

(d) A CMS decision to not conduct a hearing under paragraph (c) of this section does not disturb any potential remedy under State law for 1866(a)(1)(O) of the Act.

[63 FR 35099, June 26, 1998, as amended at 65 FR 40328, June 29, 2000; 70 FR 4738, Jan. 28, 2005]
Notes of Decisions
Cited in 17 cases (6 in the last 5 years), 2004–2025 · leading case: Christus Health Gulf Coast v. Aetna, Inc.
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Christus Health Gulf Coast v. Aetna, Inc. (2005) texapp · cites it 6× “§ 1395w-27(f)(l); 42 C.F.R. § 422.520 (a) (2003). The standard for assessing whether payment is prompt is set forth in federal regulations.”
Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Central Insurance Company (2017) ca11 · cites it 2× “42 C.F.R. § 422.520 (b) (requiring contracts between MAOs and providers to contain a prompt *588 payment provision).”
Houston Methodist Hospital v. Humana Insurance Co. (2017) txsd · cites it 5× “See 42 C.F.R. § 422.520 . The Medicare Act contains an express preemption provision stating: Relation to State laws.”
Rencare, Ltd. v. Humana Health Plan of Texas, Inc., Doing Business as Humana Health Plan of San Antonio Humana Hmo of Te (2005) ca5 “, 42 C.F.R. § 422.520 (b) (requiring contracts between M + C organizations and providers to contain a prompt payment provision); generally, the parties may negotiate their own terms.”
Medicaid & Medicare Advantage Products Ass'n of PR v. Emanuelli-Hernandez (2023) ca1 “§ 1395w-23(a); 42 C.F.R. § 422.520 (b)(2). In lieu of fixed fee-for-service reimbursements, MAOs generally receive a per-beneficiary monthly payment in return for providing coverage to Medicare Advantage enrollees for all traditional Medicare services as well as additional…”
Caris MPI v. UnitedHealthcare (2024) ca5 “42 C.F.R. § 422.520 (b)(2). Second, “[a]ny provider .”
New York City Health & Hospitals Corp. v. Wellcare of New York, Inc. (2011) nysd “510 ; and requiring payment, 42 C.F.R. § 422.520 , among others. 71 . D'Amato v.”
Shalaby v. Heritage Physician Network (2019) txsd “); see 42 C.F.R. § 422.520 (b)(1). Plaintiffs do not allege violations of the Texas Prompt Pay Act in this case.”
Main & Associates, Inc. v. Blue Cross & Blue Shield (2012) ala “” 42 C.F.R. § 422.520 (b)(1). . In light of our determination that Southern Springs’ claims arise under the Medicare Act and, therefore, are subject to the requirements of § 405(g), we pretermit consideration of the parties' arguments regarding complete or express preemption…”
South Texas Health System v. Care Improvement Plus of Texas Insurance (2016) txsd · cites it 6× “3 sets forth a 30-day period in which Care Improvement must pay a valid claim: Subject to the regulations of the State of Texas and 42 CFR 422.520 et seq., PLAN, where it is the Payor, shall pay a Valid Clean Claim within thirty (30) days of receipt of the claim unless PLAN has…”
Christus Health Gulf Coast, Christus Health Southeast Texas, Gulf Coast Division, Inc., Memorial Hermann Hospital System (2005) texapp · cites it 6× “§ 1395w-27(f)(1); 42 C.F.R. § 422.520 (a) (2003). The standard for assessing whether payment is prompt is set forth in federal regulations.”
MSPA Claims I, LLC v. Tenet Fla., Inc. (2018) flsd “2017) (noting that "the Medicare Act explicitly allows contract providers and MAOs to define the terms of their own agreements without reference to the Medicare regulations" and that "contracts between [Medicare Advantage] organizations and providers are subject to very few…”
Show all 17 citing cases →
— 42 C.F.R. § 422.520(b) — 1 case
South Texas Health System v. Care Improvement Plus of Texas Insurance (2016) txsd “3 sets forth a 30-day period in which Care Improvement must pay a valid claim: Subject to the regulations of the State of Texas and 42 CFR 422.520 et seq., PLAN, where it is the Payor, shall pay a Valid Clean Claim within thirty (30) days of receipt of the claim unless PLAN has…”
— 42 C.F.R. § 422.520(b)(1) — 1 case
Vazquez Gonzalez, Edgar J v. McS Health Management Options, Inc. (2025) prapp
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