(Medicare Claims Processing Manual)

b. Which, because of threat to the life or health of the individual, requires the use of the nearest hospital (in miles or travel time) that has a bed available and is equipped to handle the emergency.   The medical facts of your hospital admission and stay have been carefully reviewed.  Based upon this review, we have found that, although it was necessary for you to be hospitalized, a medical emergency did not exist.  There would have been time for you to have been admitted to a hospital participating in Medicare.   If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days from the date  you receive this notice.  A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.    You may send the request to our address above. Please keep a copy of any written correspondence for your files.   Sincerely,   360.3.5 - Partial Denial - Hospital- Filed or Beneficiary -Filed Emergency Claim (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   MODEL DENIAL NOTICE A (MAC'S NAME AND ADDRESS)   Date: ______________   Beneficiary: ____________________  Claim Number ________________  DETERMINATION ON EMERGENCY HOSPITAL SERVICES    This refers to your request for payment under Medicare for the services received while a patient at (hospital), from _______ through _______.  Payment can be made under the hospital insurance part of Medicare only for the costs of your hospitalization from _______ to _______.  The (hospital) does not participate in the Medicare program.  Under the law, payment for services received in a nonparticipating hospital can be made only if you go, or are brought to, the hospital to receive emergency care.  Emergency care under Medicare is defined as:   a. Care which is necessary to prevent the death or serious impairment to the health of the individual; and  b. Which, because of threat to the life or health of the individual, requires the use of the nearest hospital (in miles or travel time) which has a bed available and is equipped to handle the emergency.   Payment for emergency services stops when the emergency ends and it is permissible, from a medical standpoint, either to transfer the patient to a participating hospital or to discharge him.   The medical facts of your hospital admission and stay have been carefully reviewed.  Based upon this review, we have found that an emergency condition existed when you were admitted.  However, the medical information indicates that this emergency condition ended on ________.  At that time, your condition had improved to the extent that you could have been transferred to a hospital participating in the Medicare program.   If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days of the date you receive this notice.  A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.   Sincerely,   360.3.6 - Denial - Military Personnel/Eligible Dependents  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medica re Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   MODEL DENIAL NOTICE A (MAC'S NAME AND ADDRESS)  Date: ______________   Beneficiary: ____________________  Claim Number ________________  DETERMINATION ON EMERGENCY HOSPITAL SERVICES   We are sorry, but payment cannot be made for your stay from________ through________ at (hospital).  Under the law, medical services that have been furnished by a federal hospital to retired members of the armed services, or their eligible dependents, are not covered under the Medicare program.   If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days from the date  you receive this notice. A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.   Sincerely,   360.3.7 - Full Denial - Shipboard Claim - Beneficiary Filed  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   MODEL DENIAL NOTICE  (MACS NAME AND ADDRESS)   Date: ____________________  Beneficiary: _________________________  Claim Number: __________________  DETERMINATION ON SHIPBOARD SERVICES   We are sorry, but medical services provided on the (vessel/ship's name) cruise ship are not covered.  The Medicare program can make payment for medically necessary shipboard services only if all of the following requirements are met:   1. The services are furnished while the ship is within the territorial waters of the United States (in a U.S. port, or within 6 hours of departure or arrival at a U.S. port). 2. The services are furnished to an individual who is entitled to Part B benefits;  3. The services are furnished in connection with covered inpatient hospital services;  4. The services furnished on the ship are for the same condition that required inpatient admission;  5. The physician is legally authorized to practice in the country where he or she furnishes the services.   If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they cover these services and what procedures you should follow in submitting your claim.  If you have questions about this notice, you may call 1- 800-MEDICARE (1 -800-633-4227) for additional information.  If you believe the determination is not correct, you may request a redetermination.  You must file your request within 120 days from the date  you receive this notice.  A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.    Beneficiary name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested  Specific date(s) of service   Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.  Sincerely,   360.3.8 - Full Denial - Foreign Claim - Beneficiary Filed  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medic are card transition period and after for certain business areas that will continue to use the HICN as part of their processes.                                     MODEL DENIAL  NOTICE (MACS NAME AND ADDRESS)   Date:    Beneficiary:     Claim Number:      DETERMINATION ON FOREIGN HOSPITAL SERVICES   We are sorry, but payment cannot be made for your stay  from  through  at (hospital) in (country).  Medicare law prohibits payment for items and services furnished outside the United States except in certain limited circumstances .  The term outside the U.S. means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.  There are three situations when Medicare may pay for certain types of health care services rendered in a foreign hospital (a hospital outside the U.S.):   1. Youre in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest U.S. hospital that can treat your illness or injury.  2. Youre traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat your illness or injury. Medicare determines what qualifies as without unreasonable delay on a case -by-case basis.  3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether its an emergency.   In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.  If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they cover these services and what procedures you should follow in submitting your claim.  If you have questions about this notice, you may call 1-800- MEDICARE (1 -800-633-4227) for additional information. If you believe the determination is not correct, you may request a redetermination. You must file your request within 120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS -20027 or on a written request that includes all of the elements listed below.   Beneficiary  name   Medicare beneficiary identifier   Specific service and/or item(s) for which a redetermination is being requested   Specific date(s) of  service  Signature of the beneficiary or the beneficiarys authorized or appointed representative.   You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.  Sincerely,  370  Microvolt T -wave Alternans (MTWA)  (Rev. 3265, Issued: 05- 22-15, Effective: 01 -13-15, Implementation: 06-23-15)  On March 21, 2006, the Centers for Medicare & Medicaid Services (CMS) began national coverage of microvolt T -wave Alternans (MTWA) diagnostic testing when it was performed using only the spectral analysis (SA) method for the evaluation of patients at risk for sudden cardiac death (SCD) from ventricular arrhythmias and patients who may be candidates for Medicare coverage of the placeme nt of an implantable cardiac defibrillator (ICD).   Effective for claims with dates of service on and after January 13, 2015, Medicare Administrative Contractors (MACs) may determine coverage of MTWA diagnostic testing when it is performed using methods of analysis other than SA for the evaluation of patients at risk for SCD from ventricular arrhythmias.  Further information can be found at Publication 100-03, section 20.30, of the National Coverage Determinations Manual.   370.1 - Coding and Claims Processing for MTWA  (Rev. 12396; Issued: 12- 07-23; Effective: 01 -09-24; Implementation: 01 -09-24)