§ 414.416 - Determination of competitive bidding payment amounts.

§ 414.416 Determination of competitive bidding payment amounts.

Cross Reference

Link to an amendment published at 83 FR 57072, Nov. 14, 2018.

(a) General rule. CMS establishes a single payment amount for each item furnished under a competitive bidding program.

(b) Methodology for setting payment amount.

(1) The single payment amount for an a lead item furnished under a competitive bidding program is equal to the median of the bids maximum bid submitted for that item by suppliers whose composite bids for the product category that includes the item are equal to or below the pivotal bid for that product category. If there is an even number of bids, the single payment amount for the item is equal to the average of the two middle bids.

(2) The single payment amount for an a lead item must be less than or equal to the amount that would otherwise be paid for the same item under subpart C or subpart D of this part.

(3) In the case of competitions where bids are submitted The single payment amount for an item in a product category furnished under a competitive bidding program that is not a combination of codes for similar items within a product category as identified under § 414.412(d)(2), the single payment amount for each code within the combination of codes lead item for that product category is equal to the single payment amount for the lead item or code with the highest total nationwide allowed services in the same product category multiplied by the ratio of the average of the 2015 fee schedule amounts for all areas (i.e.that is, all states, the District of Columbia, Puerto Rico, and the United States Virgin Islands), for the code item to the average of the 2015 fee schedule amounts for all areas for the lead item.

[72 FR 18085, Apr. 10, 2007, as amended at 81 FR 77967, Nov. 4, 2016; 83 FR 57072, Nov. 14, 2018]