(2) Furnished by an ambulance that meets the definition in § 410.140 of this chapter. [53 FR 6646, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988] § 424.126 Payment to the hospital. (a) Conditions for payment. Medicare pays the hospital if it— (1) Has in effect an election that(i) Meets the requirements set forth in § 424.104; and (ii) Reflects the hospital's intent to claim for all covered services furnished during a calendar year. (2) Claims payment in accordance with §§ 424.32 and 413.74 of this chapter; and (3) Submits evidence requested by HCFA to establish that the services meet the requirements of this subpart. (b) Amount of payment. Payment is made (in accordance with §413.74 of this chapter) on the basis of 100 percent of the hospital's customary charges, subject to the applicable deductible and coinsurance provisions set forth elsewhere in this chapter. § 424.127 Payment to the beneficiary. (a) Conditions for payment of inpatient hospital services. Medicare pays the beneficiary if— (1) The hospital does not have in effect an election to claim payment; and (2) The beneficiary, or someone on his or her behalf, submits (i) A claim in accordance with § 424.32; (ii) An itemized hospital bill; and (iii) Evidence requested by HCFA to establish that the services meet the requirements of this subpart. (b) Amount payable for inpatient hospital services. The amount payable to the beneficiary is determined in accordance with § 424.109(b). (c) Conditions for payment for Part B services. Medicare pays the beneficiary for physicians' services and ambulance services as specified in § 424.121, if an itemized bill for the services is submitted by the beneficiary or someone on his or her behalf and the conditions of § 424.126(a) (2) and (3) are met. (d) The amount payable to the beneficiary is determined in accordance with § 410.152 of this chapter. Subparts I-L-[Reserved] Subpart M-Replacement and Reclamation of Medicare Payments § 424.350 Replacement of checks that are lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsements. (a) U.S. Government checks—(1) Responsibility. The Treasury Department is responsible for the investigation and settlement of claims in connection with Treasury checks issued on behalf of HCFA. (2) Action by HCFA. HCFA forwards reports of lost, stolen, defaced, mutilated, destroyed, or forged Treasury checks to the Treasury Department disbursing center responsible for issuing checks. (3) Action by the Treasury Department. The Treasury Department will replace and begin reclamation of Treasury checks in accordance with Treasury Department regulations (31 CFR parts 235, 240, and 245). (b) Intermediary and carrier benefit checks. Checks issued by intermediaries and carriers are drawn on commercial banks and are not subject to the Federal laws and Treasury Department regulations that govern Treasury checks. Replacement procedures are carried out in accordance with § 424.352 under applicable State law (including any Federal banking laws or regulations that may affect the relevant State proceedings). [58 FR 65129, Dec. 13, 1993] and carrier checks that are lost, stolen, defaced, mutilated, destroyed or paid on forged endorsements. (a) When an intermediary or carrier is notified by a payee that a check has been lost, stolen, defaced, mutilated, destroyed, or paid on forged endorsement, the intermediary or carrier contacts the commercial bank on whose paper the check was drawn and determines whether the check has been negotiated. (b) If the check has been negotiated (1) The intermediary or carrier provides the payee with a copy of the check and other pertinent information (such as a claim form, affidavit or questionnaire to be completed by the payee) required to pursue his or her claim in accordance with State law and commercial banking regulations. (2) To pursue the claim, the payee must examine the check and certify (by completing the claim form, questionnaire or affidavit) that the endorsement is not the payee's. (3) The claim form and other pertinent information is sent to the intermediary or carrier for review and processing of the claim. (4) The intermediary or carrier reviews the payee's claim. If the intermediary or carrier determines that the claim appears to be valid, it forwards the claim and a copy of the check to the issuing bank. The intermediary or carrier takes further action to recover the proceeds of the check in accordance with the State law and regulations. (5) Once the intermediary or carrier recovers the proceeds of the initial check, the intermediary or carrier issues a replacement check to the payee. (6) If the bank of first deposit refuses to settle on the check for good cause, the payee must pursue the claim on his or her own and the intermediary or carrier will not reissue the check to the payee. (c) If the check has not been negotiated (1) The intermediary or carrier arranges with the bank to stop payment on the check; and (2) Except as provided in paragraph (d), the intermediary or carrier reissues the check to the payee. (d) No check may be reissued under (c)(2) unless the claim for a replacement check is received by the intermediary or carrier no later than 1 year from the date of issuance of the original check, unless State law (including any applicable Federal banking laws or regulations that may affect the relevant State proceeding) provides a longer period which will control. [58 FR 65130, Dec. 13, 1993] FINDING AIDS A list of CFR titles, subtitles, chapters, subchapters and parts and an alphabetical list of agencies publishing in the CFR are included in the CFR Index and Finding Aids volume to the Code of Federal Regulations which is published separately and revised annually. Material Approved for Incorporation by Reference Table of CFR Titles and Chapters Alphabetical List of Agencies Appearing in the CFR Redesignation Tables List of CFR Sections Affected Material Approved for Incorporation by Reference (Revised as of October 1, 1998) The Director of the Federal Register has approved under 5 U.S.C. 552(a) and 1 CFR Part 51 the incorporation by reference of the following publications. This list contains only those incorporations by reference effective as of the revision date of this volume. Incorporations by reference found within a regulation are effective upon the effective date of that regulation. For more information on incorporation by reference, see the preliminary pages of this volume. 42 CFR (PARTS 400-429) HEALTH CARE FINANCING ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES American Hospital Association Available from: Health Care Financing Administration, Office of Chart of Accounts for Hospitals (1973 Ed.) American Lung Association (Formerly National Tuberculosis Association) 1740 Broadway, New York, NY 10019 42 CFR 405.415(b)(7)(i) Diagnostic Standards and Classification of Tuberculosis (1974 Ed.) 405.1039(b)(2) 11 West 42nd St., New York, NY 10036 Telephone: (212) 642 4900 ANSI A117.1–1971 Specifications for Making Buildings and Facilities 405.1134(c) American Psychiatric Association Division of Publications and Marketing, 1400 K Street, NW, Wash ington, DC 20005 Diagnostic and Statistical Manual of Mental Disorders, 1980 (3rd 405.243(b); Association for the Advancement of Medical Instrumentation 405.1037(a)(12) 3330 Washington Blvd., Arlington, VA 22201–4598 ASNI/AAMI RD5-1992, Hemodialysis Systems, second edition 405.2150(a); Recommended Practice for Reuse of Hemodialyzers National Academy of Sciences Academy Press, 2101 Constitution Ave., NW., Washington, DC 20418 405.2150 Recommended Dietary Allowances Current Edition, 1980 (9th Ed.) 405.1025(c)(2) |