42 CFR 414.210 - General payment rules
| Cite as | 42 CFR 414.210 |
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23 practice notes
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Almy v. Sebelius, Civil Action No. RDB–08–1245.
...amount that is equal to “80 percent of the lesser of ... the actual charge for the item; [or] the fee schedule amount for the item.” 42 C.F.R. § 414.210(a). If a DME item is denied coverage under Medicare and “neither the beneficiary nor the supplier knew, or reasonably could have been expe......
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Almy v. Sebelius, No. 10–2241.
...80 percent of the lesser of either the actual charge for the item or the fee schedule amount for the item. 42 U.S.C. § 1395m(a)(1); 42 C.F.R. § 414.210(a). The ALJ and MAC made findings that a fee schedule was properly implemented by a local contractor pursuant to guidance from the Secretar......
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Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model
...we considered two methodologies. The first method we considered for addressing price inversions (method 1) uses the methodologies at 42 CFR 414.210(g)(6) and limits the SPA for the code without the feature to the SPA for the code with the feature before the SPA is used to adjust the fee sch......
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Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model
...scenarios addressed in the proposed rule, namely, enteral infusion pumps and standard power wheelchairs. The final regulation at 42 CFR 414.210(g)(6)(i) specifically requires that in situations where a SPA for an enteral infusion pump without alarm is greater than the SPA in the same CBA fo......
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4 cases
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Almy v. Sebelius, Civil Action No. RDB–08–1245.
...amount that is equal to “80 percent of the lesser of ... the actual charge for the item; [or] the fee schedule amount for the item.” 42 C.F.R. § 414.210(a). If a DME item is denied coverage under Medicare and “neither the beneficiary nor the supplier knew, or reasonably could have been expe......
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Almy v. Sebelius, No. 10–2241.
...80 percent of the lesser of either the actual charge for the item or the fee schedule amount for the item. 42 U.S.C. § 1395m(a)(1); 42 C.F.R. § 414.210(a). The ALJ and MAC made findings that a fee schedule was properly implemented by a local contractor pursuant to guidance from the Secretar......
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United States v. Iwuala, No. 13–2497.
...a fee schedule predicated in part on a percentage of the amount claimed and, therefore, always pays less than the amount billed. See 42 C.F.R. § 414.210 (explaining that Medicare generally pays for DME “on the basis of 80 percent of the lesser of ... [t]he actual charge for the item [or] [t......
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Nichole Med. Equip. & Supply, Inc. v. United States, No. 12-364C
...to one or more beneficiaries. See generally 42 U.S.C. § 1395m(a) (2006) (providing for payment on durable medical equipment); 42 C.F.R. § 414.210 (2012) (stating payment rules). In order to be reimbursed, the supplier sends a certificate of medical necessity to a Medicare contractor. See Un......
11 firm's commentaries
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Dickinson Wright COVID-19 Resource Guide
...requirements of the IPPS. Payments for durable medical equipment (“DME”) are transitioning based on a list of factors enumerated in 42 C.F.R. 414.210. Medicare had originally established a transition period that went through December 31, 2020. However, Congress has extended these transition......
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CMS Interim Rule Makes Sweeping Changes in Response to COVID-19 Public Health Emergency
...to maintain that status. Section I. Durable Medical Equipment (DME) Interim Pricing in the CARES Act CMS is revising regulations at 42 CFR § 414.210(g)(9) to implement the CARES Act directive to increase fee schedule amounts for certain DME items and services. CMS is increasing the fee sche......
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CMS Interim Rule Makes Sweeping Changes in Response to COVID-19 Public Health Emergency
...to maintain that status. Section I. Durable Medical Equipment (DME) Interim Pricing in the CARES Act CMS is revising regulations at 42 CFR § 414.210(g)(9) to implement the CARES Act directive to increase fee schedule amounts for certain DME items and services. CMS is increasing the fee sche......
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Title III of the CARES Act: Supporting America’s Health Care System in the Fight Against the Coronavirus
...period items and services furnished in rural and noncontiguous areas will be reimbursed pursuant to the transition rule, described in 42 C.F.R. §414.210(g)(9)(iii). For areas other than rural and noncontiguous areas, items and services shall be reimbursed pursuant the transition rule descri......
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