Exceptions to Assignment of Provider’s Right to Payment – Claims Submitted to A/B MACs (Rev. 1931, Issued: 03-12-10)

by  Find-A-Code™
Jul 17th, 2015

A. Payment to Government Agency

Medicare payment for the services of a provider is not made to a governmental agency or entity except when payment to the governmental agency or entity is permissible under the other listed reassignment exceptions, e.g., where the agency is the employer of the physician.

B. Payment Pursuant to Court Order

The Medicare program may make payment in accordance with an assignment established by, or pursuant to the order of, a court of competent jurisdiction. The assignment must satisfy the conditions set forth in §30.2.

C. Payment to Agent

The Medicare program may make payment, in the name of the provider, to an agent who furnishes billing or collection services. The payment arrangement must satisfy the conditions in §30.2.4.

D. Payment to Employer

The B/MAC may pay the employer of the physician or other supplier if the physician or other supplier is required, as a condition of his employment, to turn over to his employer the fees for his services. (See §30.2.6.)

E. Payment for Services Provided Under a Contractual Arrangement

The B/MAC may make payment to an entity enrolled in the Medicare program for services provided by a physician or other person under a contractual arrangement with that entity. The services may be furnished on or off the premises of the entity submitting the claim. Both, the entity submitting the claim and receiving payment and the physician or other person under contract are subject to certain program integrity requirements. (See §30.2.7.)

F. Payment for Anti-Markup Tests

The B/MAC may pay a physician (or a physician’s medical group) or other supplier for the TC or PC of diagnostic tests (other than clinical diagnostic laboratory tests) that the physician or other supplier contracts an independent physician, medical group, or other supplier to perform. The anti-markup payment limitation applies when the performing physician or other supplier does not meet the criteria for sharing a practice with the billing physician or other supplier. The contracting physician, physician’s group, or other supplier must accept as payment in full the lower of: (a) the acquisition price; (b) the submitted charge for the service; or (c) the fee schedule amount. (See §30.2.9, of this chapter, for additional information on the anti-markup payment limitation.)

G. Payment Under Reciprocal Billing Arrangements

The B/MAC may pay the patient’s regular physician for services provided to his/her patients by another physician on an occasional reciprocal basis. (See §30.2.10.)

H. Payment Under Locum Tenens Arrangements

The B/MAC may pay the patient’s regular physician for services of a locum tenens physician during the absence of the regular physician where the regular physician pays the locum tenens on a per diem or similar fee-for-time basis, and certain other requirements are met. (See §30.2.11.)

Pub 100-04 Medicare Claims Processing Manual