(Medicare Claims Processing Manual)

The MAC will make the determination based upon all information available.  As a general rule, if the period claimed for emergency services exceeds by more than 3 to 5 days the date on which the record definitely indicates that there was substantial improve ment in the patients condition so that the patient could possibly have been moved to a participating facility or discharged without damage to health, the period beyond the 3 to 5 days is denied.  If the total period claimed for emergency services exceeds by no more than 3 to 5 days the date on which the record indicates substantial improvement in the patients condition, the entire period is allowed.   This rule is intended to screen out short stay emergency hospitalization cases in which the patient was either discharged or transferred to a participating provider within a reasonable time after the medical record definitely indicated substantial  improvem ent in the patients condition.  The reasonable period of emergency care is that period required to provide relief of acute symptoms or for initial management of the condition while arrangements are made for definitive treatment.  Two examples:    Prostatic hypertrophy which results in acute urinary retention; and    Mental illness with suicidal and/or homicidal tendencies.   In acute urinary retention, the reasonable period of emergency medical care includes the period required for catheterization and stabilization of the patient.  The patient could then be transferred to a participating hospital for surgery or other required treatment.  For the suicidal or homicidal patient, a reasonable period of emergency medical care includes the time required for initial management of the case while arrangements are made for transfer (by commitment or otherwise) to a participating hospital.  A period of 24 to 48 hours of emergency care is usually sufficient in both cases.   350.11.7  Payment Denial for Medicare Services furnished to Alien Beneficiaries Who are Not Lawfully Present in the United States  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  Medicare payment may not be made for items and services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service.   The CWF must establish an auxiliary file based on enrollment data contained in the Enrollment Data Base maintained by the Centers for Medicare & Medicaid Services in order to appropriately edit the claims specifically associated with alien beneficiaries.  The auxiliary file will be the basis for an edit that rejects claims for a beneficiary that was not lawfully present in the U.S. on the date of service.  MACs and DMACs must deny claims for items and services, rejected by CWF on the basis that the benefici ary was not lawfully present in the U.S. on the date of service. MACs and DMACs must refer to the CWF documentation on this subject for the error code MSN Message 5.7, assigned to this editing.   Upon receipt of an error code MSN Message 5.7, A/B MACs, DME MACs, and A/B MACs (HHH)  must deny the claim and use reason code (CARC) 177  Patient has not met the required eligibility requirements. When CWF rejects a claim, MACs and DMACs must use MSN message 5.7, Medicare payment may not be made for the item or service because, on the date of service, you were not lawfully present in the United States.  5.7, Medicare no puede pagar por este artculo o servicio porque, en la fecha en que lo recibi, ust ed no estaba legalmente en los Estados Unidos.  A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis that the beneficiary was lawfully present in the United States on the date of service.  In addition, this same information must be published in your next regularly scheduled bulletin.  If you have a listserv that targets the affected provider communities, you must use it to notify subscribers that information Medicare Services for Alien Bene ficiaries Lawfully present the United States is avail able on your Web site.  NOTE :  Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), codified at 8 U.S.C. 1611, prohibits aliens who are not qualified aliens from receiving Federal public benefits including Medicare.   However, Section 5561 of the Balanced Budget Act of 1997 (BBA) amended Section 401 of the PRWORA to create a Medicare exemption to the prohibition on eligibility for non- qualified alien beneficiaries, who are lawfully present in the United States and who m eet certain other conditions.  Specifically, payment may be made for services furnished to an alien who is lawfully present in the United States (and provided that with respect to benefits payable under Part A of Title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.], who was authorized to be employed with respect to any wages attributable to employment which are counted for purposes of eligibility for Medicare benefits).  The definition for lawfully present in the United States is found at 8 CF R 1.3.  350.12 - Appeals on Claims for Emergency and Foreign Services  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  When a MAC receives a beneficiary appeal of a claim submitted by the beneficiary for services provided by a non-participating provider, the MAC will process the appeal in accordance with the guidelines in Pub. 100- 04 chapter 29.   When a MAC receives an appeal from a non -participating provider of a claim that was submitted by, or on behalf of, a beneficiary, the MAC shall dismiss the appeal request as the non -participating provider is not a proper party. The MAC shall send a copy of  the dismissal to the beneficiary.  A non- participating provider does not have standing to file an appeal for the individual claims for payment it submits on behalf of a beneficiary, or for claims the beneficiary submits for services it has furnished.  See , 42 CFR 405.906(a)(3) and 405.902 (for the definition of provider); Pub. 100- 04, chapter 29, 210 and the glossary in Pub. 100- 04, chapter 29, 110 (for the definition of provider).  Only a beneficiary (or the beneficiarys authorized representative, or an appointed representative on behalf of the beneficiary) can appeal claim determinations for services furnished by a non- participating provider.  NOTE:   Non -participating providers have appeal rights under the provider and supplier enrollment appeals process in 42 CFR Part 498 for MAC determinations related to the non- participating providers election to file claims (see 350.10).   NOTE:   The RRB conducts Part B redeterminations under the Railroad Retirement Act for services rendered in Canada.   360 - Payment for Services Received By Nonparticipating Providers  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  The condition of payment regulations for emergency services received in Nonparticipating Providers can be found in the 42 CFR 424.100- 109,  Subpart G Special Conditions: Emergency Services Furnished by a Nonparticipating Hospital.  The Form CMS -1450 or its electronic equivalent must be used.  A.  Hospital Filed Claims   1.  Inpatient Services   The payment rate for inpatient claims is 100 percent of the nonparticipating providers customary charges (see 42 C.F.R. 413.74(b) and 42 C.F.R. 424.104(a)(3)).   The cost of the services is adjusted by any applicable deductible and coinsurance amounts for which the beneficiary is responsible.   Payment will be made to Federal hospitals that furnish emergency services, on an inpatient basis, to individuals entitled to hospital benefits.  Payment will be based on the lower of the actual charges from the hospital or rates published for Federal hospi tals in the Federal Register under Office of Management and Budget -  Cost of Hospital and Medical Care and Treatment Furnished by the United States; Certain Rates Regarding Recovery from Tortiously Liable Third Persons.   Medicare will not pay federal hospitals for emergency items or services furnished to veterans, retired military personnel or eligible dependents.  However, Medicare can pay for the inpatient deductible charged by VA hospitals, or credit that amount to the Medicare Part A deductible, for emergency services furnished to veterans.  If a Part A claim is denied, a denial notice will be forwarded to the beneficiary from the MAC.  The beneficiary can use this notice to forward to their private insurer, if applicable.   The VA or Department Of Defense hospital must file a statement of election for each calendar year to receive direct payment from Medicare for all claims filed that year.   2.  Outpatient Services   The amount paid by Medicare for emergency outpatient claims is obtained as follows:    Eighty- five percent of the total covered charges is the estimated cost figure.  The applicable Part B deductible is subtracted.  Coinsurance is subtracted from the remainder.    Subtracting the deductible from 85 percent of the total covered charges and applying the 20 percent coinsurance rate to the remainder obtains the patients coinsurance amount.  The hospital will be paid cost (85 percent of covered charges) minus deductible  and coinsurance.   3.  Part B Medical and Other Health Services   Part B medical and other health services, including hospital -based ambulance services whether hospital or beneficiary filed, may be covered and paid on a non- emergency basis.  To calculate the amount paid by Medicare, the hospital subtracts the Part B deductible from the total covered charges and applies the 80 percent payment rate.  4.  Special Letters for Partially or Totally Denied (Hospital- Filed) Claims for Emergency Inpatient Services   The patient receives a notice from CMS covering the emergency payment of a partially denied claim.  A denial letter and a Part B explanation of benefits is sent to the patient.  The MAC includes its address on this letter.   B.  Beneficiary Filed Claim  1.  Emergency Inpatient Claims   The payment computation follows:    Any noncovered accommodation charge is subtracted from the total accommodation charges.  The amount of the inpatient deductible or coinsurance met on this bill is subtracted.  Any remainder is multiplied by 60 percent.    The total noncovered ancillary charge is subtracted from the total ancillary charge.  Any inpatient deductible or coinsurance that remains is subtracted.  The remainder is multiplied by 80 percent.    The benefit amounts obtained are added.   2.  Emergency Outpatient Services   To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total covered charges and apply the 80 percent payment rate.   3.  Part B Medical and Other Health Services   Part B medical and other health services furnished by nonparticipating hospitals, including hospital -based ambulance services, may be covered and paid on a non- emergency basis.   To calculate the amount paid by Medicare, the hospital must subtract any applicable Part B deductible from the total covered charges and apply an 80 percent payment rate.   4.  Special Letters for Patient -Filed Claims for Emergency Inpatient Services   For emergency admissions to nonparticipating hospitals where direct payment is made to the patient, the MAC sends the beneficiary one of the letters described below, as appropriate.   The letter explains the Part A payments made.  Part B payments are made for ancillary services not covered by Part A and are also explained in a letter.  This letter also explains the beneficiarys right of appeal.   The MAC retains a duplicate of all notices sent for documentation in any appeals process.  It enters the date the notice is released on both copies of all notices.   Sample paragraphs:    Enclosed is a check for $______, which is the amount Medicare can pay for inpatient hospital services you received from (date of admission) to (date of discharge) in (hospital).    Medicare is able to pay 60 percent of the charges for your room and board plus 80 percent of the charges for all other covered services during the period (date emergency began) to (date payment ended).   Medicare is able to pay 60 percent of the charges for your room and board, 80 percent of the charges for other separately identified charges, and 66 2/3 percent of the other charges which were not separately identified on the hospital bill.    Medicare does not pay (the first $ ____ of charges) (the first three pints of blood) ($ ____ a day after the 60th day) in a benefit period.  (Select one or more, if applicable.)    If lifetime reserve days are used, add $ ___ a day from ________ to _________.    If you believe your Medicare hospital insurance should have covered all or more of your expenses, you may get in touch with us at the address shown on this letter.    If you believe that the determination is not correct, you may request a reconsideration for hospital insurance (or a review for medical insurance).  You may make the request by mail to the address shown on this letter.  If you come in person, please bring this notice with you.    This check includes a medical insurance payment for 80 percent of the charges for certain nonroutine hospital services which you received from _______ through _______.  These services are listed on the enclosed form.