Medicare_Carriers_Manual / 7065 / 7065

Why This Topic Matters

It helps readers understand which organizations may participate in Medicare Part B indirect payment arrangements and what administrative steps are involved in maintaining or ending that status. The guidance is useful for those managing plan payment workflows, approvals, and compliance with carrier and HCFA processes.

Article Sections

1. Ed. Note: For further information see

   A brief editorial note pointing to related material for additional context.

2. 7065. INDIRECT PAYMENT PROCEDURE

   An overview of the indirect payment procedure under Medicare Part B and the general circumstances in which it is used.

3. A. Basic Provision

   Introductory conditions describing the general structure of the payment arrangement and the role of the organization involved.

4. B. Organizations Which Qualify to Receive SMI Payment on Paid Bills

   The categories of organizations that may be eligible to receive Part B payment under this procedure and related plan types.

5. C. Explanation of Conditions of Payment

   Administrative conditions that must be satisfied before an organization may claim payment on covered services it has paid for.

6. D. Option to Choose Which Bills to Pay

   Discussion of how an organization may limit which bills it elects to pay and seek reimbursement for.

7. E. Meaning of "Payment in Full"

   Clarification of the payment status required for a bill and how reduced amounts are handled administratively.

8. F. Approval of Organizations

   Procedures for requesting approval to receive SMI payments, including the agencies contacted and information requested.

9. G. Approval of Additional Plans of an Organization

   Steps for adding additional plans after an organization has already been approved for the procedure.

10. H. Organization Is a Medicare Carrier

    Special approval handling when the requesting organization is itself a Medicare carrier or related entity.

11. I. Claims for Payment

    Claim filing requirements, supporting documentation, and certification language associated with requests for payment.

12. J. Explanation of Benefits

    Requirements for sending explanations of benefits when payment is made to an organization under this policy.

13. K. When Carrier Terminates An Organization's Approval

    Circumstances under which a carrier may end an organization’s approval to receive payments under the procedure.

14. L. When Regional Office Terminates An Organization's Approval

    Circumstances under which a regional office becomes responsible for termination action involving approved organizations.

15. M. General Procedures for Termination

    Procedural steps following termination, including written determinations, notification, and follow-up administration.