What basic conditions must be met for Medicare to make payment for a service under 42 CFR 424.5? Answer in under 100 words.
Details / How it works
Section 424.5 establishes the basic conditions that must be met for any claim to be paid under the Medicare program (Title XVIII of the Social Security Act). The six conditions cover the type of service, the source providing it, beneficiary eligibility, certification of medical necessity, proper claim filing, and submission of sufficient information to the Medicare contractor.
Numbers & thresholds
No specific dollar thresholds are set in § 424.5; the section instead cross-references other parts for dollar amounts (e.g., Part B deductible in § 410.160). Certification requirements are triggered when required by subpart B of Part 424.
Exceptions & edge cases
Services excluded from coverage as custodial care or not reasonable and necessary may still be reimbursable under the limitation of liability rules in 42 CFR §§ 405.332‑405.334. A nonparticipating hospital can receive payment for emergency outpatient hospital services as provided in subpart G of Part 424. Payment may also be made for inpatient hospital services furnished before notification of benefit exhaustion under § 409.68.
Sources
- [1]U.S. National Archives, Electronic Code of Federal Regulations — 42 CFR 424.5 — Basic conditions · as of 2026-08-26
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