[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR447.10]



[Page 307]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 447_PAYMENTS FOR SERVICES--Table of Contents

 

                 Subpart A_Payments: General Provisions

 

Sec.  447.10  Prohibition against reassignment of provider claims.



    (a) Basis and purpose. This section implements section 1902(a)(32) 

of the Act which prohibits State payments for Medicaid services to 

anyone other than a provider or recipient, except in specified 

circumstances.

    (b) Definitions. For purposes of this section:

    Facility means an institution that furnishes health care services to 

inpatients.

    Factor means an individual or an organization, such as a collection 

agency or service bureau, that advances money to a provider for accounts 

receivable that the provider has assigned, sold or transferred to the 

individual organization for an added fee or a deduction of a portion of 

the accounts receivable. Factor does not include a business 

representative as described in paragraph (f) of this section.

    Organized health care delivery system means a public or private 

organization for delivering health services. It includes, but is not 

limited to, a clinic, a group practice prepaid capitation plan, and a 

health maintenance organization.

    (c) State plan requirements. A State plan must provide that the 

requirements of paragraphs (d) through (h) of this section are met.

    (d) Who may receive payment. Payment may be made only--

    (1) To the provider; or

    (2) To the recipient if he is a noncash recipient eligible to 

receive the payment under Sec.  447.25; or

    (3) In accordance with paragraphs (e), (f), and (g) of this section.

    (e) Reassignments. Payment may be made in accordance with a 

reassignment from the provider to a government agency or reassignment by 

a court order.

    (f) Business agents. Payment may be made to a business agent, such 

as a billing service or an accounting firm, that furnishes statements 

and receives payments in the name of the provider, if the agent's 

compensation for this service is--

    (1) Related to the cost of processing the billing;

    (2) Not related on a percentage or other basis to the amount that is 

billed or collected; and

    (3) Not dependent upon the collection of the payment.

    (g) Individual practitioners. Payment may be made to--

    (1) The employer of the practitioner, if the practitioner is 

required as a condition of employment to turn over his fees to the 

employer;

    (2) The facility in which the service is provided, if the 

practitioner has a contract under which the facility submits the claim; 

or

    (3) A foundation, plan, or similar organization operating an 

organized health care delivery system, if the practitioner has a 

contract under which the organization submits the claim.

    (h) Prohibition of payment to factors. Payment for any service 

furnished to a recipient by a provider may not be made to or through a 

factor, either directly or by power of attorney.



[43 FR 45253, Sept. 29, 1978, as amended at 46 FR 42672, Aug. 24, 1981; 

61 FR 38398, July 24, 1996]



[[Page 308]]