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Stark Law Guidelines



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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