42 CFR 424.507 - Ordering covered items and services for Medicare beneficiaries.

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There are 8 Updates appearing in the Federal Register for 42 CFR 424. View below or at eCFR (GPOAccess)
§ 424.507 Ordering covered items and services for Medicare beneficiaries.
(a) Conditions for payment of claims for ordered covered imaging and clinical laboratory services and items of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)—
(1) Ordered covered imaging, clinical laboratory services, and DMEPOS item claims. To receive payment for ordered imaging, clinical laboratory services, and DMEPOS items (excluding home health services described in § 424.507(b), and Part B drugs), a provider or supplier must meet all of the following requirements:
(i) The ordered covered imaging, clinical laboratory services, and DMEPOS items (excluding home health services described in paragraph (b) of this section, and Part B drugs) must have been ordered by a physician or, when permitted, an eligible professional (as defined in § 424.506(a) of this part).
(ii) The claim from the provider or supplier must contain the legal name and the National Provider Identifier (NPI) of the physician or the eligible professional (as defined in § 424.506(a) of this part) who ordered the item or service.
(iii) The physician or, when permitted, other eligible professional, as defined in § 424.506(a), who ordered the item or service must—
(A) Be identified by his or her legal name;
(B) Be identified by his or her NPI; and
(C) (1) Be enrolled in Medicare in an approved status; or
(2) Have validly opted-out of the Medicare program.
(iv) If the item or service is ordered by—
(A) An unlicensed resident (as defined in § 413.75), or by a non-enrolled licensed resident (as defined in § 413.75), the claim must identify a teaching physician, who must be enrolled in Medicare in an approved status, as follows:
(1) As the ordering supplier.
(2) By his or her legal name.
(3) By his/her NPI.
(B) A licensed resident (as defined in § 413.75), he or she must have a provisional license or be otherwise permitted by State law, where the resident is enrolled in an approved graduate medical education program, to practice or order such items and services, the claim must identify by legal name and NPI the—
(1) Resident, who is enrolled in Medicare in an approved status to order; or
(2) Teaching physician, who is enrolled in Medicare in an approved status.
(2) Part B beneficiary claims. To receive payment for ordered covered items and services listed at § 424.507(a), a beneficiary's claim must meet all of the following requirements:
(i) The physician or, when permitted, other eligible professional (as defined § 424.506(a)) who ordered the item or service must—
(A) Be identified by his or her legal name; and
(B) (1) Be enrolled in Medicare in an approved status; or
(2) Have validly opted out of the Medicare program.
(ii) If the item or service is ordered by—
(A) An unlicensed resident (as defined in § 413.75) or a non-enrolled licensed resident, (as defined in § 413.75) the claim must identify a teaching physician, who must be enrolled in Medicare in an approved status as follows:
(1) As the ordering supplier.
(2) By his or her legal name.
(B) A licensed resident (as defined in § 413.75), he or she must have a provisional license or are otherwise permitted by State law, where the resident is enrolled in an approved graduate medical education program, to practice or to order such items and services, the claim must identify by legal name the—
(1) Resident, who is enrolled in Medicare in an approved status to order; or
(2) Teaching physician, who is enrolled in Medicare in an approved status.
(b) Conditions for payment of claims for covered home health services. To receive payment for covered Part A or Part B home health services, a provider's home health services claim must meet all of the following requirements:
(1) The ordering/certifying physician must meet all of the following requirements:
(i) Be identified by his or her legal name.
(ii) Be identified by his or her NPI.
(iii)
(A) Be enrolled in Medicare in an approved status; or
(B) Have validly opted-out of the Medicare program.
(2) If the services were ordered/certified by—
(i) An unlicensed resident, as defined in § 413.75, or by a non-enrolled licensed resident, as defined in § 413.75, the claim must identify a teaching physician who must be enrolled in Medicare in an approved status—
(A) As the ordering/certifying supplier;
(B) By his or her legal name; and
(C) By his or her NPI.
(ii) A licensed resident (as defined in § 413.75), he or she must have a provisional license or are otherwise permitted by State law, where the resident is enrolled in an approved graduate medical education program, to practice or to order/certify such items and services, the claim must identify by legal name and NPI the—
(A) Resident, who is enrolled in Medicare in an approved status to order; or
(B) Teaching physician, who is enrolled in Medicare in an approved status.
(c) Denial of provider- or supplier-submitted claims. Notwithstanding § 424.506(c)(3), a Medicare contractor denies a claim from a provider or a supplier for covered items and services described in paragraph (a) or (b) of this section if the claim does not meet the requirements of paragraphs (a)(1) and (b) of this section, respectively.
(d) Denial of beneficiary-submitted claims. A Medicare contractor denies a claim from a Medicare beneficiary for covered items or services described in paragraphs (a) and (b) of this section if the claim does not meet the requirements of paragraph (a)(2) of this section.
[77 FR 25317, Apr. 27, 2012]

Title 42 published on 2013-10-01

The following are only the Rules published in the Federal Register after the published date of Title 42.

For a complete list of all Rules, Proposed Rules, and Notices view the Rulemaking tab.

  • 2014-05-23; vol. 79 # 100 - Friday, May 23, 2014
    1. 79 FR 29844 - Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Final rule.
      Effective Dates: These regulations are effective on July 22, 2014 except for the amendment in instruction 27 to § 423.100, the amendment in instruction 30 to § 423.501, and the amendment in instruction 34 to § 423.505, which are effective on January 1, 2016. Applicability Dates: In the SUPPLEMENTARY INFORMATION section of this final rule, we provide a table (Table 1) which lists key changes in this final rule that have an applicability date other than the effective date of this final rule.
      42 CFR Parts 417, 422, 423, and 424

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United States Code

Title 42 published on 2013-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR 424 after this date.

  • 2014-05-23; vol. 79 # 100 - Friday, May 23, 2014
    1. 79 FR 29844 - Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Final rule.
      Effective Dates: These regulations are effective on July 22, 2014 except for the amendment in instruction 27 to § 423.100, the amendment in instruction 30 to § 423.501, and the amendment in instruction 34 to § 423.505, which are effective on January 1, 2016. Applicability Dates: In the SUPPLEMENTARY INFORMATION section of this final rule, we provide a table (Table 1) which lists key changes in this final rule that have an applicability date other than the effective date of this final rule.
      42 CFR Parts 417, 422, 423, and 424