C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 424—CONDITIONS FOR MEDICARE PAYMENT › Subpart C—Claims for Payment

42 C.F.R. § 424.32

Basic requirements for all claims

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(a) A claim must meet the following requirements:

(1) A claim must be filed with the appropriate intermediary or carrier on a form prescribed by CMS in accordance with CMS instructions.

(2) A claim for physician services, clinical psychologist services, or clinical social worker services must include appropriate diagnostic coding for those services using ICD-9-CM.

(3) A claim must be signed by the beneficiary or on behalf of the beneficiary (in accordance with § 424.36).

(4) A claim must be filed within the time limits specified in § 424.44.

(5) All Part B claims for services furnished to SNF residents (whether filed by the SNF or by another entity) must include the SNF's Medicare provider number and appropriate HCPCS coding.

(b) The prescribed forms for claims are the following:

CMS-1450—Uniform Institutional Provider Bill. (This form is for institutional provider billing for Medicare inpatient, outpatient and home health services.) CMS-1490S—Request for Medicare payment. (For use by a patient to request payment for medical expenses.) CMS-1500—Health Insurance Claim Form. (For use by physicians and other suppliers to request payment for medical services.) CMS-1660—Request for Information-Medicare Payment for Services to a Patient now Deceased. (For use in requesting amounts payable under title XVIII to a deceased beneficiary.)

(c) Where claims forms are available. Excluding forms CMS-1450 and CMS-1500, all claims forms prescribed for use in the Medicare program are distributed free-of-charge to the public, institutions, or organizations. The CMS-1450 and CMS-1500 may be obtained only by commercial purchase. All other claims forms can be obtained upon request from CMS or any Social Security branch or district office, or from Medicare intermediaries or carriers. The CMS-1490S is also available at local Social Security Offices.

(d) Submission of electronic claims—(1) Definitions. For purposes of this paragraph, the following terms have the following meanings:

(i) Claim means a transaction defined at 45 CFR 162.1101(a).

(ii) Electronic claim means a claim that is submitted via electronic media. A claim submitted via direct data entry is considered to be an electronic claim.

(iii) Direct data entry is defined at 45 CFR 162.103.

(iv) Electronic media is defined at 45 CFR 160.103.

(v) Initial Medicare claim means a claim submitted to Medicare for payment under Part A or Part B of the Medicare Program under title XVIII of the Act for initial processing, including claims sent to Medicare for the first time for secondary payment purposes. Initial Medicare claim excludes any adjustment or appeal of a previously submitted claim, and claims submitted for payment under Part C of the Medicare program under title XVIII of the Act.

(vi) Physician, practitioner, facility, or supplier is a Medicare provider or supplier other than a provider of services.

(vii) Provider of services means a provider of services as defined in section 1861(u) of the Act.

(viii) Small provider of services or small supplier means—

(A) A provider of services with fewer than 25 full-time equivalent employees; or

(B) A physician, practitioner, facility, or supplier with fewer than 10 full-time equivalent employees.

(2) Submission of electronic claims required. Except for claims to which paragraph (d)(3) or (d)(4) of this section applies, an initial Medicare claim may be paid only if submitted as an electronic claim for processing by the Medicare fiscal intermediary or carrier that serves the physician, practitioner, facility, supplier, or provider of services. This requirement does not apply to any other transactions, including adjustment or appeal of the initial Medicare claim.

(3) Exceptions to requirement to submit electronic claims. The requirement of paragraph (d)(2) of this section is waived for any initial Medicare claim when—

(i) There is no method available for the submission of an electronic claim. This exception includes claims submitted by Medicare beneficiaries and situations in which the standard adopted by the Secretary at 45 FR 162.1102 does not support all of the information necessary for payment of the claim. The Secretary may identify situations coming within this exception in guidance.

(ii) The entity submitting the claim is a small provider of services or small supplier.

(4) Unusual cases. The Secretary may waive the requirement of paragraph (d)(2) of this section in unusual cases as the Secretary finds appropriate. Unusual cases are deemed to exist in the following situations:

(i) The submission of dental claims.

(ii) There is a service interruption in the mode of submitting the electronic claim that is outside the control of the entity submitting the claim, for the period of the interruption.

(iii) The entity submitting the claim submits fewer than 10 claims to Medicare per month, on average.

(iv) The entity submitting the claim only furnishes services outside of the U.S. territory.

(v) On demonstration, satisfactory to the Secretary, of other extraordinary circumstances precluding submission of electronic claims.

(5) Effective date. This paragraph (d) is effective October 16, 2003, and applies to claims submitted on or after October 16, 2003.

[53 FR 6639, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988, as amended at 59 FR 10299, Mar. 4, 1994; 63 FR 26311, May 12, 1998; 63 FR 53307, Oct. 5, 1998; 66 FR 39601, July 31, 2001; 68 FR 48813, Aug. 15, 2003; 70 FR 71020, Nov. 25, 2005; 71 FR 48143, Aug. 18, 2006; 72 FR 66405, Nov. 27, 2007]
Notes of Decisions
Cited in 25 cases (3 in the last 5 years), 1999–2025 · leading case: United States Ex Rel. Prather v. Brookdale Senior Living Cmtys., Inc., 892 F.3d 822 (6th Cir. 2018).
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United States Ex Rel. Prather v. Brookdale Senior Living Cmtys., Inc., 892 F.3d 822 (6th Cir. 2018). · cites it 4× “§§ 1302 , 1395hh ; 42 C.F.R. § 424.32 . Providers must use the forms indicated by the regulations.”
Loma Linda Univ. Med. Ctr. v. Sebelius, 684 F. Supp. 2d 42 (D.D.C. 2010). · cites it 4× “Two provisions of the Part A regulations are particularly relevant here: 42 C.F.R. § 424.32 and 42 C.F.R. § 424.44 .”
Am. Hosp. Ass'n v. Azar, 895 F.3d 822 (D.C. Cir. 2018). · cites it 2× “42 C.F.R. § 424.32 . If dissatisfied with the contractor's initial determination, the hospital then may pursue within HHS various other avenues for redetermination, reconsideration, hearings, and appeals.”
United States Ex Rel. Riley v. St. Luke's Episcopal Hosp., 355 F.3d 370 (5th Cir. 2004). “§ 1395y(a)(l)(A) (proscribing payment under Medicare Part A or Part B unless items or services are "reasonable and necessary”); see also 42 C.F.R. § 424.32 (b) (requiring the use of these forms for claims).”
United States ex rel. Raffington v. Bon Secours Health Sys., Inc., 285 F. Supp. 3d 759 (S.D. Ill. 2018). “Because "the Form provides that, 'No Part B Medicare Benefits may be paid unless this form is received as required by existing law and regulations ( 42 CFR 424.32 ),' " the claim alleged by the proposed amendments is that submitting Form 1500 is material to the Government's…”
Mikes v. Straus, 274 F.3d 687 (2d Cir. 2001). · cites it 2× “As required by the Medicare implementing regulations, see 42 C.F.R. § 424.32 (2000), defendants submitted Medicare reimbursement claims for spiro-metry on form “HCFA-1500” or an electronic equivalent.”
Am. Hosp. Ass'n v. Azar, 385 F. Supp. 3d 1 (D.C. Cir. 2019). “See 42 C.F.R. § 424.32 . "If dissatisfied with the contractor's initial determination, the hospital then may pursue within HHS various other avenues for redetermination, reconsideration, hearings, and appeals.”
In re Cardiac Devices Qui Tam Litig., 221 F.R.D. 318 (D. Conn. 2004). “42 C.F.R. § 424.32 . The UB-82 claim forms, used until 1994, contained a “Remarks” box on the form where the hospitals were instructed to enter any remarks not shown elsewhere on the bill but which were necessary for proper payment.”
Visiting Nurse Serv. of New York Home Care v. New York State Dep't of Health, 840 N.E.2d 577 (NY 2005). “Providers submit claims to the federal agency’s fiscal intermediary for evaluation (see 42 CFR 424.32 [a] [1]) and this *503 assessment process uses criteria established by federal law and regulations.”
United States ex rel. Kalec v. Nuwaye Monitoring, LLC, 84 F. Supp. 3d 793 (N.D. Ill. 2015). · cites it 2× “Nu-Wave is required to certify the accuracy of each claim pursuant to 42 C.F.R. §§ 424.32 (a)(3), 424.33. While Medicare allows physicians to provide neuro-moni-toring services to multiple patients at one time, it only reimburses doctors for their actual time spent monitoring…”
United States ex rel. Bilotta v. Novartis Pharm. Corp., 50 F. Supp. 3d 497 (S.D.N.Y. 2014). “” Both the form, which further provides [that] “[n]o Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations,” and the Medicare Regulations, see 42 C.F.R. § 424.32 , state that certification is a precondition to Medicare…”
United States Ex Rel. DeCesare v. Americare in Home Nursing, 757 F. Supp. 2d 573 (E.D. Va. 2010). “42 C.F.R. § 424.32 . At the end of the fiscal year, providers must also submit reports listing all costs to be reimbursed.”
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