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Stark Law Guidelines

CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

Basis and scope.	411.1

Conclusive effect of QIO determinations on payment of claims.	411.2

Services for which neither the beneficiary nor any other person is legally obligated to pay.	411.4

Services furnished by a Federal provider of services or other Federal agency.	411.6

Services that must be furnished at public expense under a Federal law or Federal Government contract.	411.7

Services paid for by a Government entity.	411.8

Services furnished outside the United States.	411.9

Services required as a result of war.	411.10

Charges imposed by an immediate relative or member of the beneficiary's household.	411.12

Particular services excluded from coverage.	411.15

Basis and scope.	411.20

Definitions.	411.21

Beneficiary's cooperation.	411.23

Recovery of conditional payments.	411.24

Third party payer's notice of mistaken Medicare primary payment.	411.25

Subrogation and right to intervene.	411.26

Waiver of recovery and compromise of claims.	411.28

Effect of third party payment on benefit utilization and deductibles.	411.30

Authority to bill third party payers for full charges.	411.31

Basis for Medicare secondary payments.	411.32

Amount of Medicare secondary payment.	411.33

Limitations 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.	411.35

Amount of Medicare recovery when a third party payment is made as a result of a judgment or settlement.	411.37

General provisions.	411.40

Beneficiary's responsibility with respect to workers' compensation.	411.43

Basis for conditional Medicare payment in workers' compensation cases.	411.45

Apportionment of a lump-sum compromise settlement of a workers' compensation claim.	411.47

General provisions.	411.50

Beneficiary's responsibility with respect to no-fault insurance.	411.51

Basis for conditional Medicare payment in liability cases.	411.52

Basis for conditional Medicare payment in no-fault cases.	411.53

Limitation on charges when a beneficiary has received a liability insurance payment or has a claim pending against a liability insurer.	411.54

Basis and scope.	411.100

Definitions.	411.101

Basic prohibitions and requirements.	411.102

Prohibition against financial and other incentives.	411.103

Current employment status.	411.104

Aggregation rules.	411.106

Taking into account entitlement to Medicare.	411.108

Basis for determination of nonconformance.	411.110

Documentation of conformance.	411.112

Determination of nonconformance.	411.114

Notice of determination of nonconformance.	411.115

Appeals.	411.120

Hearing procedures.	411.121

Hearing officer's decision.	411.122

Administrator's review of hearing decision.	411.124

Reopening of determinations and decisions.	411.126

Referral to Internal Revenue Service (IRS).	411.130

Scope	411.160

Prohibition against taking into account Medicare eligibility or entitlement or differentiating benefits.	411.161

Medicare benefits secondary to group health plan benefits.	411.162

Coordination of benefits: Dual entitlement situations.	411.163

Basis for conditional Medicare payments.	411.165

General provisions.	411.170

Medicare benefits secondary to group health plan benefits.	411.172

Basis for Medicare primary payments.	411.175

Basis.	411.200

Definitions.	411.201

Medicare benefits secondary to LGHP benefits.	411.204

Basis for Medicare primary payments and limits on secondary payments.	411.206

Scope of subpart.	411.350

Definitions.	411.351

Group practice.	411.352

Prohibition on certain referrals by physicians and limitations on billing.	411.353

Financial relationship, compensation, and ownership or investment interest.	411.354

General exceptions to the referral prohibition related to both ownership/investment and compensation.	411.355

Exceptions to referral prohibitions related to ownership or investment interests.	411.356

Exceptions to referral prohibitions related to compensation arrangements.	411.357

Group practice attestation.	411.360

Reporting requirements.	411.361

Advisory opinions relating to physician referrals.	411.370

Procedure for submitting a request.	411.372

Certification.	411.373

Fees for the cost of advisory opinions.	411.375

Expert opinions from outside sources.	411.377

Withdrawing a request.	411.378

When CMS accepts a request.	411.379

When CMS issues a formal advisory opinion.	411.380

CMS's right to rescind advisory opinions.	411.382

Disclosing advisory opinions and supporting information.	411.384

CMS's advisory opinions as exclusive.	411.386

Parties affected by advisory opinions.	411.387

When advisory opinions are not admissible evidence.	411.388

Range of the advisory opinion.	411.389

Payment for custodial care and services not reasonable and necessary.	411.400

Indemnification of beneficiary.	411.402

Criteria for determining that a beneficiary knew that services were excluded from coverage as custodial care or as not reasonable and necessary.	411.404

Criteria for determining that a provider, practitioner, or supplier knew that services were excluded from coverage as custodial care or as not reasonable and necessary.	411.406

Refunds of amounts collected for physician services not reasonable and necessary, payment not accepted on an assignment-related basis.	411.408

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