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FEDERAL · 42 CFR

Part 411 — Exclusions from Medicare and Limitations on Medicare Payment

94 sections · Title 42: Public Health

§ 411.1Basis and scope.
§ 411.2Conclusive effect of QIO determinations on payment of claims.
§ 411.4Items and services for which neither the beneficiary nor any other person is legally obligated to pay.
§ 411.6Services furnished by a Federal provider of services or other Federal agency.
§ 411.7Services that must be furnished at public expense under a Federal law or Federal Government contract.
§ 411.8Services paid for by a Government entity.
§ 411.9Services furnished outside the United States.
§ 411.10Services required as a result of war.
§ 411.12Charges imposed by an immediate relative or member of the beneficiary's household.
§ 411.15Particular services excluded from coverage.
§ 411.20Basis and scope.
§ 411.21Definitions.
§ 411.22Reimbursement obligations of primary payers and entities that received payment from primary payers.
§ 411.23Beneficiary's cooperation.
§ 411.24Recovery of conditional payments.
§ 411.25Primary payer's notice of primary payment responsibility.
§ 411.26Subrogation and right to intervene.
§ 411.28Waiver of recovery and compromise of claims.
§ 411.30Effect of primary payment on benefit utilization and deductibles.
§ 411.31Authority to bill primary payers for full charges.
§ 411.32Basis for Medicare secondary payments.
§ 411.33Amount of Medicare secondary payment.
§ 411.35Limitations on charges to a beneficiary or other party when a workers' compensation plan, a no-fault insurer, or an employer group health plan is primary payer.
§ 411.37Amount of Medicare recovery when a primary payment is made as a result of a judgment or settlement.
§ 411.39Automobile and liability insurance (including self-insurance), no-fault insurance, and workers' compensation: Final conditional payment amounts via Web portal.
§ 411.40General provisions.
§ 411.43Beneficiary's responsibility with respect to workers' compensation.
§ 411.45Basis for conditional Medicare payment in workers' compensation cases.
§ 411.46Lump-sum payments.
§ 411.47Apportionment of a lump-sum compromise settlement of a workers' compensation claim.
§ 411.50General provisions.
§ 411.51Beneficiary's responsibility with respect to no-fault insurance.
§ 411.52Basis for conditional Medicare payment in liability cases.
§ 411.53Basis for conditional Medicare payment in no-fault cases.
§ 411.54Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.
§ 411.100Basis and scope.
§ 411.101Definitions.
§ 411.102Basic prohibitions and requirements.
§ 411.103Prohibition against financial and other incentives.
§ 411.104Current employment status.
§ 411.106Aggregation rules.
§ 411.108Taking into account entitlement to Medicare.
§ 411.110Basis for determination of nonconformance.
§ 411.112Documentation of conformance.
§ 411.114Determination of nonconformance.
§ 411.115Notice of determination of nonconformance.
§ 411.120Appeals.
§ 411.121Hearing procedures.
§ 411.122Hearing officer's decision.
§ 411.124Administrator's review of hearing decision.
§ 411.126Reopening of determinations and decisions.
§ 411.130Referral to Internal Revenue Service (IRS).
§ 411.160Scope.
§ 411.161Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.
§ 411.162Medicare benefits secondary to group health plan benefits.
§ 411.163Coordination of benefits: Dual entitlement situations.
§ 411.165Basis for conditional Medicare payments.
§ 411.170General provisions.
§ 411.172Medicare benefits secondary to group health plan benefits.
§ 411.175Basis for Medicare primary payments.
§ 411.200Basis.
§ 411.201Definitions.
§ 411.204Medicare benefits secondary to LGHP benefits.
§ 411.206Basis for Medicare primary payments and limits on secondary payments.
§ 411.350Scope of subpart.
§ 411.351Definitions.
§ 411.352Group practice.
§ 411.353Prohibition on certain referrals by physicians and limitations on billing.
§ 411.354Financial relationship, compensation, and ownership or investment interest.
§ 411.355General exceptions to the referral prohibition related to both ownership/investment and compensation.
§ 411.356Exceptions to the referral prohibition related to ownership or investment interests.
§ 411.357Exceptions to the referral prohibition related to compensation arrangements.
§ 411.361Reporting requirements.
§ 411.362Additional requirements concerning physician ownership and investment in hospitals.
§ 411.363Process for requesting an exception from the prohibition on facility expansion.
§ 411.370Advisory opinions relating to physician referrals.
§ 411.372Procedure for submitting a request.
§ 411.373Certification.
§ 411.375Fees for the cost of advisory opinions.
§ 411.377Expert opinions from outside sources.
§ 411.378Withdrawing a request.
§ 411.379When CMS accepts a request.
§ 411.380When CMS issues a formal advisory opinion.
§ 411.382CMS' right to rescind advisory opinions.
§ 411.384Disclosing advisory opinions and supporting information.
§ 411.386CMS's advisory opinions as exclusive.
§ 411.387Effect of an advisory opinion.
§ 411.388When advisory opinions are not admissible evidence.
§ 411.389Range of the advisory opinion.
§ 411.400Payment for custodial care and services not reasonable and necessary.
§ 411.402Indemnification of beneficiary.
§ 411.404Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
§ 411.406Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary.
§ 411.408Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.