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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 7. SOCIAL SECURITY |
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SubChapter XVIII. HEALTH INSURANCE FOR AGED AND DISABLED |
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Part B. Supplementary Medical Insurance Benefits for Aged and Disabled |
§ 1395n. Procedure for payment of claims of providers of services
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(a) Conditions for payment for services described in section 1395k(a)(2) of this title Except as provided in subsections (b), (c), and (e) of this section, payment for services described in section 1395k(a)(2) of this title furnished an individual may be made only to providers of services which are eligible therefor under section 1395cc(a) of this title, and only if— (1) written request, signed by such individual, except in cases in which the Secretary finds it impracticable for the individual to do so, is filed for such payment in such form, in such manner and by such person or persons as the Secretary may by regulation prescribe, no later than the close of the period ending 1 calendar year after the date of service; and (2) a physician, or, in the case of services described in subparagraph (A), a physician enrolled under section 1395cc(j) of this title, certifies (and recertifies, where such services are furnished over a period of time, in such cases, with such frequency, and accompanied by such supporting material, appropriate to the case involved, as may be provided by regulations) that— (A) in the case of home health services (i) such services are or were required because the individual is or was confined to his home (except when receiving items and services referred to in section 1395x(m)(7) of this title) and needs or needed skilled nursing care (other than solely venipuncture for the purpose of obtaining a blood sample) on an intermittent basis or physical or speech therapy or, in the case of an individual who has been furnished home health services based on such a need and who no longer has such a need for such care or therapy, continues or continued to need occupational therapy, (ii) a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician, (iii) such services are or were furnished while the individual is or was under the care of a physician, and (iv) in the case of a certification after January 1, 2010 , prior to making such certification the physician must document that the physician, or a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1395x(aa)(5) of this title) who is working in collaboration with the physician in accordance with State law, or a certified nurse-midwife (as defined in section 1395x(gg) of this title) as authorized by State law, or a physician assistant (as defined in section 1395x(aa)(5) of this title) under the supervision of the physician, has had a face-to-face encounter (including through use of telehealth and other than with respect to encounters that are incident to services involved) with the individual during the 6-month period preceding such certification, or other reasonable timeframe as determined by the Secretary;(B) in the case of medical and other health services, except services described in subparagraphs (B), (C), and (D) of section 1395x(s)(2) of this title, such services are or were medically required; (C) in the case of outpatient physical therapy services or outpatient occupational therapy services, (i) such services are or were required because the individual needed physical therapy services or occupational therapy services, respectively, (ii) a plan for furnishing such services has been established by a physician or by the qualified physical therapist or qualified occupational therapist, respectively, providing such services and is periodically reviewed by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician; (D) in the case of outpatient speech pathology services, (i) such services are or were required because the individual needed speech pathology services, (ii) a plan for furnishing such services has been established by a physician or by the speech pathologist providing such services and is periodically reviewed by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician; (E) in the case of comprehensive outpatient rehabilitation facility services, (i) such services are or were required because the individual needed skilled rehabilitation services, (ii) a plan for furnishing such services has been established and is periodically reviewed by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician; and (F) in the case of partial hospitalization services, (i) the individual would require inpatient psychiatric care in the absence of such services, (ii) an individualized, written plan for furnishing such services has been established by a physician and is reviewed periodically by a physician, and (iii) such services are or were furnished while the individual is or was under the care of a physician. For purposes of this section, the term “provider of services” shall include a clinic, rehabilitation agency, or public health agency if, in the case of a clinic or rehabilitation agency, such clinic or agency meets the requirements of section 1395x(p)(4)(A) of this title (or meets the requirements of such section through the operation of subsection (g) or (ll)(2) of section 1395x of this title), or if, in the case of a public health agency, such agency meets the requirements of section 1395x(p)(4)(B) of this title (or meets the requirements of such section through the operation of subsection (g) or (ll)(2) of section 1395x of this title), but only with respect to the furnishing of outpatient physical therapy services (as therein defined) or (through the operation of subsection (g) or (ll)(2) of section 1395x of this title) with respect to the furnishing of outpatient occupational therapy services or outpatient speech-language pathology services, respectively. To the extent provided by regulations, the certification and recertification requirements of paragraph (2) shall be deemed satisfied where, at a later date, a physician makes a certification of the kind provided in subparagraph (A) or (B) of paragraph (2) (whichever would have applied), but only where such certification is accompanied by such medical and other evidence as may be required by such regulations. With respect to the physician certification required by paragraph (2) for home health services furnished to any individual by a home health agency (other than an agency which is a governmental entity) and with respect to the establishment and review of a plan for such services, the Secretary shall prescribe regulations which shall become effective no later than July 1, 1981 , and which prohibit a physician who has a significant ownership interest in, or a significant financial or contractual relationship with, such home health agency from performing such certification and from establishing or reviewing such plan, except that such prohibition shall not apply with respect to a home health agency which is a sole community home health agency (as determined by the Secretary). For purposes of the preceding sentence, service by a physician as an uncompensated officer or director of a home health agency shall not constitute having a significant ownership interest in, or a significant financial or contractual relationship with, such agency. For purposes of paragraph (2)(A), an individual shall be considered to be “confined to his home” if the individual has a condition, due to an illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered “confined to his home”, the condition of the individual should be such that there exists a normal inability to leave home and that leaving home requires a considerable and taxing effort by the individual. Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be “confined to his home”. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. In applying paragraph (1), the Secretary may specify exceptions to the 1 calendar year period specified in such paragraph.(b) Conditions for payment for services described in section 1395x(s) of this title (1) Payment may also be made to any hospital for services described in section 1395x(s) of this title furnished as an outpatient service by a hospital or by others under arrangements made by it to an individual entitled to benefits under this part even though such hospital does not have an agreement in effect under this subchapter if (A) such services were emergency services, (B) the Secretary would be required to make such payment if the hospital had such an agreement in effect and otherwise met the conditions of payment hereunder, and (C) such hospital has made an election pursuant to section 1395f(d)(1)(C) of this title with respect to the calendar year in which such emergency services are provided. Such payments shall be made only in the amounts provided under section 1395l(a)(2) of this title and then only if such hospital agrees to comply, with respect to the emergency services provided, with the provisions of section 1395cc(a) of this title. (2) Payment may also be made on the basis of an itemized bill to an individual for services described in paragraph (1) of this subsection if (A) payment cannot be made under such paragraph (1) solely because the hospital does not elect, in accordance with section 1395f(d)(1)(C) of this title, to claim such payments and (B) such individual files application (submitted within such time and in such form and manner, and containing and supported by such information as the Secretary shall by regulations prescribe) for reimbursement. The amounts payable under this paragraph shall, subject to the provisions of section 1395l of this title, be equal to 80 percent of the hospital’s reasonable charges for such services. (c) Collection of charges from individuals for services specified in section 1395x(s) of this title Notwithstanding the provisions of this section and sections 1395k, 1395l, and 1395cc(a)(1)(A) of this title, a hospital or a critical access hospital may, subject to such limitations as may be prescribed by regulations, collect from an individual the customary charges for services specified in section 1395x(s) of this title and furnished to him by such hospital as an outpatient, but only if such charges for such services do not exceed the applicable supplementary medical insurance deductible, and such customary charges shall be regarded as expenses incurred by such individual with respect to which benefits are payable in accordance with section 1395l(a)(1) of this title. Payments under this subchapter to hospitals which have elected to make collections from individuals in accordance with the preceding sentence shall be adjusted periodically to place the hospital in the same position it would have been had it instead been reimbursed in accordance with section 1395l(a)(2) of this title (or, in the case of a critical access hospital, in accordance with section 1395l(a)(6) of this title).
(d) Payment to Federal provider of services or other Federal agencies prohibited Subject to section 1395qq of this title, no payment may be made under this part to any Federal provider of services or other Federal agency, except a provider of services which the Secretary determines is providing services to the public generally as a community institution or agency; and no such payment may be made to any provider of services or other person for any item or service which such provider or person is obligated by a law of, or a contract with, the United States to render at public expense.
(e) Payment to fund designated by medical staff or faculty of medical school For purposes of services (1) which are inpatient hospital services by reason of paragraph (7) of section 1395x(b) of this title or for which entitlement exists by reason of clause (II) of section 1395k(a)(2)(B)(i) of this title, and (2) for which the reasonable cost thereof is determined under section 1395x(v)(1)(D) of this title (or would be if section 1395ww of this title did not apply), payment under this part shall be made to such fund as may be designated by the organized medical staff of the hospital in which such services were furnished or, if such services were furnished in such hospital by the faculty of a medical school, to such fund as may be designated by such faculty, but only if— (A) such hospital has an agreement with the Secretary under section 1395cc of this title, and (B) the Secretary has received written assurances that (i) such payment will be used by such fund solely for the improvement of care to patients in such hospital or for educational or charitable purposes and (ii) the individuals who were furnished such services or any other persons will not be charged for such services (or if charged provision will be made for return of any moneys incorrectly collected).
Amendments
2010—Subsec. (a). Pub. L. 111–148, § 6404(a)(2)(B)(ii), inserted at end of concluding provisions “In applying paragraph (1), the Secretary may specify exceptions to the 1 calendar year period specified in such paragraph.”
Subsec. (a)(1). Pub. L. 111–148, § 6404(a)(2)(B)(i), substituted “period ending 1 calendar year after the date of service;” for “period of 3 calendar years following the year in which such services are furnished (deeming any services furnished in the last 3 calendar months of any calendar year to have been furnished in the succeeding calendar year) except that, where the Secretary deems that efficient administration so requires, such period may be reduced to not less than 1 calendar year;”.
Subsec. (a)(2). Pub. L. 111–148, § 6405(b)(2), as amended by Pub. L. 111–148, § 10604, inserted “, or, in the case of services described in subparagraph (A), a physician enrolled under section 1395cc(j) of this title,” after “a physician” in introductory provisions.
Subsec. (a)(2)(A)(iv). Pub. L. 111–148, § 10605(b), inserted “, or a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1395x(aa)(5) of this title) who is working in collaboration with the physician in accordance with State law, or a certified nurse-midwife (as defined in section 1395x(gg) of this title) as authorized by State law, or a physician assistant (as defined in section 1395x(aa)(5) of this title) under the supervision of the physician,” after “must document that the physician”.
Pub. L. 111–148, § 6407(a)(2), added cl. (iv).
2008—Subsec. (a). Pub. L. 110–275, in second sentence, substituted “subsection (g) or (ll)(2) of section 1395x of this title” for “section 1395x(g) of this title” wherever appearing and inserted “or outpatient speech-language pathology services, respectively” before period at end.
2003—Subsec. (a). Pub. L. 108–173 substituted “leave home and” for “leave home,” in fifth sentence of concluding provisions.
2000—Subsec. (a). Pub. L. 106–554, in concluding provisions, struck out “, and that absences of the individual from home are infrequent or of relatively short duration, or are attributable to the need to receive medical treatment” after “taxing effort by the individual” and inserted at end “Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited, to furnish adult day-care services in the State shall not disqualify an individual from being considered to be ‘confined to his home’. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.”
1997—Subsec. (a)(2)(A). Pub. L. 105–33, § 4615(a), inserted “(other than solely venipuncture for the purpose of obtaining a blood sample)” after “skilled nursing care”.
Subsec. (c). Pub. L. 105–33, § 4201(c)(1), substituted “critical access” for “rural primary care” in two places.
1990—Subsec. (c). Pub. L. 101–508 substituted “a hospital or a rural primary care hospital may” for “a hospital may” in first sentence, substituted “section 1395l(a)(2) of this title (or, in the case of a rural primary care hospital, in accordance with section 1395l(a)(6) of this title)” for “section 1395l(a)(2) of this title” in second sentence, and struck out at end “A rural primary care hospital shall be considered a hospital for purposes of this subsection.”
1989—Subsec. (a)(2)(G), (H). Pub. L. 101–234 repealed Pub. L. 100–360, §§ 203(d)(1), 205(d), and provided that the provisions of law amended or repealed by such sections are restored or revived as if such sections had not been enacted, see 1988 Amendment notes below.
Subsec. (c). Pub. L. 101–239 inserted at end “A rural primary care hospital shall be considered a hospital for purposes of this subsection.”
1988—Subsec. (a)(2)(G). Pub. L. 100–360, § 203(d)(1), added subpar. (G) relating to home intravenous drug therapy services.
Subsec. (a)(2)(H). Pub. L. 100–360, § 205(d), added subpar. (H) relating to in-home care provided to chronically dependent individuals.
1987—Subsec. (a). Pub. L. 100–203, § 4024(b), inserted two sentences at end clarifying “confined to his home” for purposes of par. (2)(A).
Subsec. (a)(2)(C)(i). Pub. L. 100–203, § 4085(i)(4), struck out second comma at end.
Subsec. (a)(2)(F). Pub. L. 100–203, § 4070(b)(3), added subpar. (F).
1986—Subsec. (a). Pub. L. 99–509, § 9337(c)(2), inserted in second sentence “(or meets the requirements of such section through the operation of section 1395x(g) of this title)” in two places, and “or (through the operation of section 1395x(g) of this title) with respect to the furnishing of outpatient occupational therapy services”.
Subsec. (a)(2)(C). Pub. L. 99–509, § 9337(c)(1), inserted “or outpatient occupational therapy services” in introductory provisions, “or occupational therapy services, respectively,” in cl. (i), and “or qualified occupational therapist, respectively,” in cl. (ii).
1984—Subsec. (a). Pub. L. 98–369, § 2354(b)(1), as amended by Pub. L. 98–617, § 3(a)(3), in concluding provisions, substituted “contractual” for “contractural”.
Pub. L. 98–369, § 2336(b), inserted before period at end of fourth sentence “, except that such prohibition shall not apply with respect to a home health agency which is a sole community home health agency (as determined by the Secretary)”.
Pub. L. 98–369, § 2336(a), inserted sentence at end that for purposes of the preceding sentence, service by a physician as an uncompensated officer or director of a home health agency shall not constitute having a significant ownership interest in, or a significant financial or contractual relationship with, such agency.
Subsec. (a)(2)(B), (C). Pub. L. 98–369, § 2354(b)(8)(A), struck out “and” at end.
Subsec. (a)(2)(C)(ii). Pub. L. 98–369, § 2342(b), substituted “by a physician or by the qualified physical therapist providing such services and is periodically reviewed by a physician” for “, and is periodically reviewed, by a physician”.
Subsec. (a)(2)(D). Pub. L. 98–369, § 2354(b)(8)(B), realigned margin of subpar. (D).
Subsec. (e)(2). Pub. L. 98–369, § 2354(b)(9), designated concluding pars. (1) and (2) as (A) and (B), respectively, and in par. (B) inserted “(i)” after “written assurances that” and substituted “(ii) the individuals who” for “(B) the individuals who” and “return of” for “return for”.
1983—Subsec. (e). Pub. L. 98–21 inserted “(or would be if section 1395ww of this title did not apply)” after “section 1395(v)(1)(D) of this title”.
1981—Subsec. (a)(2)(A). Pub. L. 97–35, § 2122(a)(1), substituted “needs or needed skilled nursing care on an intermittent basis or physical or speech therapy or, in the case of an individual who has been furnished home health services based on such a need and who no longer has such a need for such care or therapy, continues or continued to need occupational therapy” for “needed skilled nursing care on an intermittent basis, or physical, occupational, or speech therapy”.
Subsec. (a)(2)(D). Pub. L. 97–35, § 2106(b)(1), inserted “and” after “physician;”.
Subsec. (a)(2)(E). Pub. L. 97–35, § 2106(b)(1), substituted a period for “; and” at the end.
1980—Subsec. (a). Pub. L. 96–499, § 930(e), inserted sentence at end authorizing Secretary to prescribe regulations to prohibit significantly interested physicians from performing physician certification required by par. (2) for home health services.
Subsec. (a)(2)(A). Pub. L. 96–499, § 930(j), substituted “physical, occupational, or speech” for “physical or speech”.
Subsec. (a)(2)(D)(ii). Pub. L. 96–499, § 944(a), inserted “by a physician or by the speech pathologist providing such services”, after “has been established”.
Subsec. (a)(2)(E). Pub. L. 96–499, § 933(b), added subpar. (E).
1976—Subsec. (d). Pub. L. 94–437 substituted “Subject to section 1395qq of this title, no payment” for “No payment”.
1972—Subsec. (a). Pub. L. 92–603, § 227(e)(2)(A), inserted reference to subsec. (e) of this section in introductory provisions.
Subsec. (a)(1). Pub. L. 92–603, § 281(f), placed a 3-year time limitation on time within which a written request for payment is filed, with provision for reduction of limit to 1 year.
Subsec. (a)(2)(C). Pub. L. 92–603, § 251(b)(2), substituted “because the individual needed physical therapy services” for “because the individual needed physical therapy services on an outpatient basis”.
Subsec. (a)(2)(D). Pub. L. 92–603, § 283(b), added subpar. (D).
Subsec. (c). Pub. L. 92–603, § 204(b), substituted “the applicable supplementary medical insurance deductible” for “$50”.
Subsec. (e). Pub. L. 92–603, § 227(e)(2)(B), added subsec. (e).
1968—Subsec. (a). Pub. L. 90–248, §§ 129(c)(9)(A), 130(a), inserted introductory exception phrase and included reference to subsec. (c).
Subsec. (a)(2). Pub. L. 90–248, § 133(e)(5), inserted sentence at end defining “provider of services”.
Subsec. (a)(2)(B). Pub. L. 90–248, §§ 126(b), 133(e)(4), inserted “except services described in subparagraphs (B) and (C) of section 1395x(s)(2) of this title,” after “health services,” and inserted reference to subpar. (d).
Subsec. (a)(2)(C). Pub. L. 90–248, § 133(e)(1)–(3), added subpar. (C).
Subsec. (b). Pub. L. 90–248, § 129(c)(9)(B), added subsec. (b). Former subsec. (b) redesignated (c), in turn redesignated (d).
Subsec. (c). Pub. L. 90–248, § 130(b), added subsec. (c). Former subsec. (c), previously designated (b), redesignated (d).
Subsec. (d). Pub. L. 90–248, §§ 129(c)(9)(B), 130(b), redesignated former subsec. (b) as (c), in turn as (d), respectively.
Effective Date Of Amendment
Amendment by section 6404(a)(2)(B) of Pub. L. 111–148 applicable to services furnished on or after
Amendment by section 6405(b)(2) of Pub. L. 111–148 applicable to written orders and certifications made on or after
Amendment by Pub. L. 110–275 applicable to services furnished on or after
Amendment by Pub. L. 106–554 applicable to home health services furnished on or after
Amendment by section 4201(c)(1) of Pub. L. 105–33 applicable to services furnished on or after
Amendment by section 4615(a) of Pub. L. 105–33 applicable to home health services furnished after 6-month period beginning after
Amendment by Pub. L. 101–234 effective
Amendment by section 203(d)(1) of Pub. L. 100–360 applicable to items and services furnished on or after
Amendment by section 205(d) of Pub. L. 100–360 applicable to items and services furnished on or after
Amendment by section 4024(b) of Pub. L. 100–203 applicable to items and services provided on or after
Amendment by Pub. L. 99–509 applicable to expenses incurred for outpatient occupational therapy services furnished on or after
Amendment by Pub. L. 98–617 effective as if originally included in the Deficit Reduction Act of 1984, Pub. L. 98–369, see section 3(c) of Pub. L. 98–617, set out as a note under section 1395f of this title.
Amendment by section 2336(a) of Pub. L. 98–369 applicable to certifications and plans of care made or established on or after
Pub. L. 98–369, div. B, title III, § 2342(c),
Amendment by section 2354(b)(1), (8), (9) of Pub. L. 98–369 effective
Amendment by Pub. L. 98–21 applicable to items and services furnished by or under arrangement with a hospital beginning with its first cost reporting period that begins on or after
Amendment by section 2122(a)(1) of Pub. L. 97–35 applicable to services furnished pursuant to plans of treatment implemented after the third month beginning after
Amendment by section 930(e), (j) of Pub. L. 96–499 effective with respect to services furnished on or after
Amendment by section 933(b) of Pub. L. 96–499 effective with respect to a comprehensive outpatient rehabilitation facility’s first accounting period beginning on or after
Pub. L. 96–499, title IX, § 944(b),
Amendment by section 204(b) of Pub. L. 92–603 effective with respect to calendar years after 1972, see section 204(c) of Pub. L. 92–603, set out as a note under section 1395l of this title.
Amendment by section 227(e)(2) of Pub. L. 92–603 applicable with respect to accounting periods beginning after
Amendment by section 251(b)(2) of Pub. L. 92–603 applicable with respect to services furnished on or after
Amendment by section 281(f) of Pub. L. 92–603 applicable in the case of services furnished (or deemed to have been furnished) after 1970, see section 281(g) of Pub. L. 92–603, set out as a note under section 1395gg of this title.
Pub. L. 92–603, title II, § 283(c),
Amendment by section 126(b) of Pub. L. 90–248 applicable with respect to services furnished after
Amendment by section 129(c)(9)(A), (B) of Pub. L. 90–248 applicable with respect to services furnished after
Pub. L. 90–248, title I, § 130(c),
Amendment by section 133(e) of Pub. L. 90–248 applicable with respect to services furnished after
Miscellaneous
Secretary of Health and Human Services required to provide, not later than 90 days after
Pub. L. 108–173, title VI, § 647,
Pub. L. 100–203, title IV, § 4027,