(Medicare Claims Processing Manual)

Emergency coverage, particularly Part B emergency outpatient coverage, is broader than the nonemergency Part B Medical and Other Health Services coverage provisions.  When the emergency requirements are met, program payment may be made to the hospital for the full range of outpatient hospital services.  In addition to the nonemergency coverage list, emergency coverage includes hospital services (including drugs and biologicals -  blood is a biological -  which cannot be self -administered), "incident to physicians' services rende red to outpatients," and outpatient physical therapy and speech -language pathology.  The latter two services are not covered under the nonemergency provisions.  Payment for "incident to" services can be only under the emergency rather than the nonemergency provisions.  Whether Part B payment is made under the emergency or nonemergency provisions, it may be made for diagnostic laboratory tests furnished by an emergency hospital only if the hospital meets the conditions of participation relating to hospital laboratories.  It may be made only for radiology services furnished by an emergency hospital if the hospital meets the conditions of participation relating to radiology departments.  Part B payment may be made for diagnostic laboratory tests furnished by a nonparticipati ng hospital which is not an emergency hospital only if the hospital laboratory meets the conditions of coverage of independent laboratories and for radiology services furnished by it, only if it meets the conditions of participation relating to radiology departments.   C.  Claims Processing   The hospital enters the annotation "nonemergency- hospital accepts assignment" in Remarks of the Form CMS -1450.  If it is determined that some or all of the services are not covered under the nonemergency provisions, the claim is returned to it (if hospital- filed) or to the beneficiary (if patient- filed) to determine whether the services might be covered as emergency services.   350.10 - Elections to Bill for Services Rendered By Nonparticipating Hospitals  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  A.  Nonparticipating U.S. Hospitals   As a nonparticipating U.S. hospital meeting emergency requirements, the hospital has the option to bill the program during a calendar year by filing an election with its MAC.  If it files an election, it should submit claims for the following services furnished all Medicare beneficiaries throughout the year:    Emergency inpatient services; and    Emergency outpatient services.   In addition, the hospital may not bill any beneficiary beyond deductibles, coinsurance, and noncovered services in that calendar year.  It must agree to refund any monies incorrectly collected.  It may not file an election for the calendar year if it has a lready charged any beneficiary for covered services furnished in that year.   If the hospital does not file a billing election, the beneficiary can file a claim.  The beneficiary may request information from the hospital or the MAC as appropriate.   During November of each year, the MAC will send the non- participating hospital a letter (see 360.3.1).  Also, during November of each year, the MAC will send a letter to each domestic hospital, giving it an opportunity to elect to bill Medicare if it has not been doing so ( 360.3.2).   If during the year the hospital requests to bill the program, its MAC will send the model letter in 360.3.3.  B.  Billing for Services Furnished Prior to Certification   The following rules apply if a bill is submitted for services rendered before and after a hospital's certification (participation) date:    PPS hospitals are paid the DRG, if the date of discharge is after the certification date.    Other hospitals are paid for services rendered after the certification date.  However, the hospital must include services before certification date on its cost report.   It should annotate in the upper right hand corner of the claim "Emergency Conversion."   C.  Foreign Hospitals   Foreign hospitals may submit a statement to the appropriate MAC stating that they will bill for all claims.  If they do not, the beneficiary may claim the payment.  When the MAC is aware that a hospital is willing to bill the program for all covered servic es, it solicits the hospital's agreement to:    Bill for all covered services for the calendar year (except for deductible and coinsurance amounts);    Not bill the beneficiary for any amounts other than for deductible and coinsurance and charges for noncovered services; and    Refund to the beneficiary any monies incorrectly collected.   A hospital may not file an election for a calendar year if it has charged any beneficiary for covered services during that year.   D.  Submitting Claims   The beneficiary or the hospital that has elected to bill the program may submit emergency claims for payment to the appropriate MAC for evaluation of accessibility or emergency factors.   The hospital completes the claim (Form CMS -1450 or electronic equivalent) according to billing instructions in chapter 25.  It enters "hospital filed emergency admission" in Item 94 "Remarks."  It sends the completed bill and the necessary emergency documentation (Form CMS -1771, Attending Physicians Statement and Documentation of Medicare Emergency) or medical records to substantiate the emergency to the appropriate MAC.   NOTE:   See 360.2, "Designated Contractors."   If the hospital submits a claim but has not filed an election to bill the program, the MAC will contact the hospital to determine if it is qualified and wish to bill the program.  If it declines, the claim will be denied.  A claim will be solicited from th e beneficiary.   If the hospital has filed a billing election and the beneficiary files a claim, the beneficiary's claim is denied and the MAC  contacts the hospital regarding the claim.   350.11 - Processing Claims  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  All claims are subject to development to determine whether the Medicare secondary payer provisions apply.  (See Pub. 100-05, Medicare Secondary Payer Manual.)   A.  Nonparticipating Hospitals   The processing MAC is responsible for making accessibility and medical emergency determinations for physician and ambulance services.   1.  Claims Subject to Technical Denials   The following claims are subject to technical denial:   Foreign nonemergency services claims if:    The residence requirement is not met.  (See 350.5.)    The hospital rendering the service does not meet Joint Commission or equivalent accreditation requirements set by a hospital approval program of the country in which it is located.    The accessibility requirements are not met.  (See 350.11.4.)    Canadian travel claims when the requirements in 350.4 are not met.    Emergency services claims for which the hospital does not meet the definition of an emergency hospital.   Claims for which the query response shows the beneficiary is not entitled to benefits.    Any foreign claim when Part A benefits are exhausted and Part B physician or ambulance claims are not involved.  2.  Either the Accessibility or Medical Emergency Requirements are Not Met   Claim is denied but retained in case of an appeal by the beneficiary.   NOTE:   Even though Part A or Part B emergency services furnished by U.S. hospitals are denied, Part B payment may be possible for Medical and Other Health Services specified in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 6.  Claim is retained in case o f an appeal by the beneficiary.   3.  Emergency Services Partially Denied   When the medical emergency is approved but not for the entire period, the claim is processed and payment made for the covered period.   B.  Foreign Part B Physician and Ambulance Claims   The hospital must attach any Part B claim for foreign physician and ambulance services to the corresponding Part A claim and forward to the MAC.  If the MAC determines that the inpatient services were covered, it sends the physician and/or independent ambulance claim to the designated MAC for processing and payment.  (See 350.6.)   If the Part A claim is denied on the basis of accessibility of medical emergency, the MAC denies the Part B claim, and sends a MSN to the beneficiary.  It retains copies in case of an appeal by the beneficiary.   NOTE:   Even though Part A benefits are totally or partially exhausted, payment may be made by the MAC for physician and independent ambulance services furnished if all coverage requirements are met.   If a Part A claim was partially denied because the emergency terminated, the MAC makes a decision on the claim and any provider -based ambulance claim.  It sends copies to the appropriate MAC for processing.  350.11.1 - Contractors Designated to Process Foreign Claims  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  Per contractor Statement of Work (SOW) all contractors are designated to process claims for physicians and ambulance services furnished in connection with a covered foreign hospital stay for their beneficiaries who reside in the states/areas for which they process claims.   All contractors are designated to determine whether the requirements in 350.6 are met for claims for inpatient services based upon the geographic location of the foreign hospitals furnishing the services.   All contractors are designated to process these claims if there is evidence that the Part B services were furnished in connection with covered foreign inpatient hospital services.  If there is no evidence, the Contractor must send a front -end rejection not ice in accordance with 350.11.2.   350.11.2 - Contractor Processing Guidelines  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  Per contractor Statement of Work (SOW) all contractors are responsible for processing foreign, emergency and shipboard claims for their beneficiaries who reside in the states/areas for which they process claims.   The A/B MAC determines whether the requirements in 350.6.A  are met.  If these requirements are not met, the A/B MAC denies the Part A claim and related Part B claim and notifies the beneficiary.  Where the A/B MAC determines that the requirements in 350.6.A are met, the A/B MAC determines whether other applicabl e Part A coverage requirements are met.  If the A/B MAC disallows the Part A claim, it denies the related Part B claim and notifies the beneficiary.  However, the A/B MAC will not be involved in the processing of foreign claims if, for any reason, the related Part A claim is denied.   If the claim does not show that the beneficiary was hospitalized, the A/B MAC sends the beneficiary a front -end rejection notice.  In filling out the Notification of Medicare Determination, the A/B MACs should check other and include the following explanation:  Foreign physician or ambulance services are not covered unless they were furnished in connection with a covered inpatient stay.   350.11.3 - Medicare Approved Charges for Services Rendered in Canada or Mexico  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  For Canadian services, the Medicare approved charge will be the lower of:   1. The allowed amount for the same service in the U.S. locality closest to where the service was furnished (as determined by the designated MAC), or   2. The Canadian Provincial fee.   Therefore, the designated MAC must obtain the most recent schedule of fees published by the appropriate Canadian Province.  Most of the designated MACs deal with only one Provincial schedule.  For Mexican services, the maximum charge is the Medicare allowed amount for the same service in the locality closest to where the service was furnished (as determined by the designated MAC).   350.11.4 - Accessibility Criteria (Rev. 4111, Issued: 08- 10-18, Effective: 9 -11-18, Implementation: 9- 11-18)  A.  Emergency Claims   The MAC uses the same criteria in domestic and foreign emergency claims.  This includes services in a foreign religious non-medical health care institution and Canadian Travel claims.  (See 350.4 and 350.9.)   Emergency determinations take into account such matters as relative distances of a participating hospital, and road conditions.  The MAC considers whether the nature of the emergency required immediate transportation to the nearest available hospital (i.e. , the nonparticipating hospital) or, without hazard to the patient, would have permitted the additional transportation time to take the patient to a more distant participating hospital in the same general area.   The MAC does not consider in its determination such factors involving selection of a hospital which reflect the personal preferences of the individual or physician, (e.g., physician does not have staff privileges at the participating hospital) nearness to beneficiary's residence, presence of previous medical records at the nonparticipating hospital, cost, or type of accommodations available.   The following sections discuss documentation of the accessibility requirement and provide guidelines for making a determination where the participating hospital is:   Closer to the site of the emergency than is the admitting nonparticipating hospital;    Fifteen or fewer miles farther from the site of the emergency than is the nonparticipating hospital; or    Sixteen or more miles farther from the site of the emergency than is the admitting nonparticipating hospital.   In urban and suburban areas, where both participating and nonparticipating hospitals are similarly available, it is presumed, in the absence of clear and convincing evidence to the contrary, that the services could have been provided in the participating h ospital.   1.  Participating Hospital Closer to Site of Emergency