(a) As a basis for Medicare payment, the following conditions must be met:
(1) Types of services. The services must be—
(i) Covered services, as specified in part 409 or part 410 of this chapter; or
(ii) Services excluded from coverage as custodial care or services not reasonable and necessary, but reimbursable in accordance with §§ 405.332 through 405.334 of this chapter, pertaining to limitation of liability.
(2) Sources of services. The services must have been furnished by a provider, nonparticipating hospital, or supplier that was, at the time it furnished the services, qualified to have payment made for them.
(3) Beneficiary of services. Except as provided in § 409.68 of this chapter, the services must have been furnished while the individual was eligible to have payment made for them. (Section 409.68 provides for payment of inpatient hospital services furnished before the hospital is notified that the beneficiary has exhausted the Medicare benefits available for the current benefit period.)
(4) Certification of need for services. When required, the provider must obtain certification and recertification of the need for the services in accordance with subpart B of this part.
(5) Claim for payment. The provider, supplier, or beneficiary, as appropriate, must file a claim that includes or makes reference to a request for payment, in accordance with subpart C of this part.
(6) Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
(b) Additional conditions applicable in certain circumstances or to certain services are set forth in other sections of this part.
[53 FR 6635, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 60 FR 38271, July 26, 1995]
Notes of Decisions
In re Cardiac Devices Qui Tam Litig., 221 F.R.D. 318 (D. Conn. 2004).
· cites it 3× “) The Medicare regulations require the providers to furnish to the fiscal intermediaries sufficient information to determine if payment was due and the amount of payment see 42 C.F.R. § 424.5 (a)(6). 18 (Harper-Hutzel Compl.”
United States Ex Rel. Groat v. Boston Heart Diagnostics Corp., 255 F. Supp. 3d 13 (D.D.C. 2017).
“§ 13951 (e); 42 C.F.R. § 424.5 (a)(6)). Boston Heart’s argument to the contrary is belied not only by coúrt decisions reviewing Medicare coverage determinations for claims submitted by laboratories in which the government determined that the tests at issue were not medically…”
Almy v. Sebelius, 749 F. Supp. 2d 315 (D. Maryland 2010).
“§ 1395Í (e); 42 C.F.R. § 424.5 (a)(6). In addition, an electronic DME claim must include a Healthcare Common Procedure Coding System (“HCPCS”) billing code.”
Nelson v. Jackson (D. Maryland 2019).
· cites it 2× “” Nelson argues that “he did not have any Accounts Receivables because he did not file” Medicare claims for payment of medical services he provided as a physician, pursuant to 42 C.F.R. § 424.5 (a)(5).7 ECF 17 at 17. Because Nelson “stopped billing,” he asserts “there was…”
Jackson v. Nelson (Bankr. D. Md. 2019).
· cites it 2× “” Nelson argues that “he did not have any Accounts Receivables because he did not file” Medicare claims for payment of medical services he provided as a physician, pursuant to 42 C.F.R. § 424.5 (a)(5).? ECF 17 at 17. Because Nelson “stopped billing,” he asserts “there was…”
— 42 C.F.R. § 424.5(a)(5) — 1 case
Jackson v. Nelson (Bankr. D. Md. 2019).
“” Nelson argues that “he did not have any Accounts Receivables because he did not file” Medicare claims for payment of medical services he provided as a physician, pursuant to 42 C.F.R. § 424.5 (a)(5).? ECF 17 at 17. Because Nelson “stopped billing,” he asserts “there was…”
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