Medicare_Carriers_Manual / 5246 / 5246

Why This Topic Matters

It helps readers understand when standard charge screens may need adjustment and what procedural steps Medicare carriers were expected to follow when reviewing and documenting nonstandard charge situations.

Article Sections

1. 5246. Use of Inherent Reasonableness for Reimbursement of Medicare Charges--Non-Physician Services

   Introduces the topic and explains the general context for reviewing Medicare reimbursement charges for non-physician services.

2. Circumstances That May Lead to Grossly Excessive or Grossly Deficient Charges

   Summarizes the types of market, cost, technology, and locality-related conditions discussed as reasons a standard charge calculation may be inadequate.

3. Factors That May Be Considered in Setting a Reasonable Charge

   Outlines broad categories of information that may be used when a carrier must evaluate whether a charge limit is reasonable.

4. Other Situations Where Inherent Reasonableness May Be Considered

   Describes additional circumstances in which the same review concept may be relevant beyond the most obvious charge extremes.

5. Documentation and Comment Procedures

   Covers recordkeeping, explanation, documentation, and notice expectations associated with applying the methodology.

6. Examples of Application

   Provides illustrative scenarios showing the general kinds of situations in which carriers applied or considered the criterion.

7. Special Note

   Notes a historical review requirement and continuation of certain established limits under specified conditions.

8. Review and Prospective Application

   Addresses ongoing review of reasonable charge screens and the timing of applying determinations to claims.