evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
350.5 - Services Furnished in a Foreign Hospital Nearest to Beneficiary's U.S. Residence  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  Coverage is provided for inpatient hospital services furnished in a foreign hospital that is closer to, or substantially more  accessible from, the beneficiary's U.S. residence than the nearest available participating U.S. hospital that is adequately equipped to deal with the illness or injury, whether or not an emergency existed and without regard to where the illness or injury occurred.   "Residence" means the beneficiary's fixed and permanent home to which they intend to return whenever they are away or a dwelling where the beneficiary periodically spends some time (e.g., a summer home).   The foreign hospital must meet accreditation requirements equivalent to Joint Commission standards.  For example, the Canadian Council on Hospital Accreditation (CCHA) has equivalent requirements.  Thus, Canadian hospitals accredited by the CCHA meet the q ualifying requirements.  In the case of Mexican hospitals, the Dallas or San Francisco RO makes the determination, depending upon the hospital's location.  Claims for services provided in countries other than Canada or Mexico should be sent to the MAC that  is responsible for the state or territory where the emergency arose.  In other words, the foreign claim would be processed similarly to how claims are processed in the state or territory where the emergency arose.   See 350.11.4 below for discussion of accessibility criteria.   Some claims for services furnished in a foreign hospital nearest to the beneficiary's U.S. residence will not be "emergency."  In these nonemergency situations, it may be necessary to deny payment in whole or part, (even though it has been approved with re gard to accessibility) because the services are not medically reasonable and necessary or involve custodial care (i.e., exclusions under 1862(a)(1) and (9)).  However, in the case of denials under the medical necessity and custodial care exclusions, the MAC applies the limitation on liability considerations under 1879 of the Act before issuing the denial notice.
(Medicare Claims Processing Manual)
The MAC examines claims involving medical necessity or custodial care denials to determine if there is any evidence that the beneficiary (or the person acting on behalf of the beneficiary) was aware that the beneficiary did not require, or no longer requir ed, a covered level of care.  The foreign hospital, since it is not participating, is not under any obligation to furnish a written notice of noncoverage to a beneficiary in order to protect itself from being held liable under the 1879 waiver of liability provision.  However, there may be instances where the medical records of the denied foreign claim show that the beneficiary was advised that the beneficiary did not require, or no longer required, Medicare covered services, (e.g., written notice of noncoverage from the hospital's staff or a prior CMS denial notice).  It will probably be rare where a finding is made that the beneficiary had knowledge of noncoverage, so that, generally, payments are made under the waiver of liability provision.  The MAC uses  appropriate Medicare Summary Notice (MSN) and Remittance Advice denial messages for determinations involving the limitation on liability provision.  For additional information regarding the application of the 1879 liability provisions, see Pub 100- 04, chapter 30.   350.6  Coverage of Physician and Ambulance Services Furnished Outside U.S.  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  Payment is made for necessary physician and ambulance services that meet the other coverage requirements of the Medicare program, and are furnished in connection with a covered foreign hospitalization.  A.  Coverage of Physician and Ambulance Services Furnished Outside the U.S.  Where inpatient services in a foreign hospital are covered, payment may also be made for:    Physicians services furnished to the beneficiary while he/she is an inpatient,   Physicians services furnished to the beneficiary outside the hospital on the day of his/her admission as an inpatient, provided the services were for the same condition for which the beneficiary was hospitalized (including the services of a physician who furnishes emergency services in Canadian waters on the day the  patient is admitted to a Canadian hospital for a covered emergency stay) and,
(Medicare Claims Processing Manual)
Ambulance services, where necessary, for the trip to the hospital in conjunction with the beneficiarys admission as an inpatient.  Return trips from a foreign hospital are not covered.   In cases involving foreign ambulance services, the general requirements in chapter 15 are also applicable, subject to the following special rules:    If the foreign hospitalization was determined to be covered on the basis of emergency services, the medical necessity requirements outlined in chapter 15 are considered met.    The definition of physician, for purposes of coverage of services furnished outside the U.S., is expanded to include a foreign practitioner, provided the practitioner is legally licensed to practice in the country in which the services are furnished.    Only the beneficiary may file for Part B benefits.  The assignment method may not be used.  However, where the beneficiary is deceased, the rule for settling Part B underpayments is applicable, i.e., payment may be made to the foreign physician or ambulanc e company on the basis of an unpaid bill, provided the physician or ambulance company accepts the MACs reasonable charge determination as the full charge.    The regular deductible and coinsurance requirements apply to physician and ambulance services.   350.7 - Claims for Services Furnished in Canada to Qualified Railroad Retirement Beneficiaries  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  All claims for hospital and/or related physician or ambulance services furnished in Canada to qualified railroad retirement beneficiaries (QRRBs) are forwarded first to the Railroad Retirement Board (RRB).  Under the Railroad Retirement Act, payment is made b y the RRB to Qualified Railroad Retirement Beneficiaries (QRRB) for covered hospital services furnished in Canadian hospitals as well as in the U.S.  The Railroad Retirement Act does not cover physician and ambulance services; however, under an agreement between CMS and RRB, if the QRRB claims payment for Part B services in connection with Canadian hospitalization, RRB processes the Part B claim.  In such cases the RRB determines:    Whether the requirements in 350.1.B  and 350.6 are met in regard to the inpatient services; and   Whether the requirements in 350.6.A  are met in regard to the physician and/or ambulance services were furnished in connection with the services
(Medicare Claims Processing Manual)
If either is not met, RRB denies the claim and notifies the beneficiary.  If met, RRB refers the claim to the RRB MAC, Palmetto GBA, to determine if the coverage criteria for physician and/or ambulance services are met.   The hospital must forward all claims for services furnished QRRBs in Canada to:   Retirement Medicare Section  U.S. Railroad Retirement Board  844 North Rush Street  Chicago, IL 60611- 2092   If a QRRB is a resident of Canada, Medicare payments are reduced by the amount of payment made for the same services by the Canadian Provincial Health Insurance Plan.   B.  Claims for services furnished in other foreign countries   The RRB does not pay for health care services furnished in Mexico or any foreign countries other than Canada.   All claims for inpatient hospital services and/or related physician or ambulance services furnished in Mexico to QRRBs should be forwarded directly to the Railroad Retirement Board.  If the Railroad Retirement Board determines that the requirements in 350.6.A are not met, the Railroad Retirement Board will deny the claim and send notice to the beneficiary.  If the requirements in 350.6.A or B are met, the Railroad Retirement Board will hold any potentially allowable Part B claim until an MAC  determination regarding the coverage of Part A services has been made.  When the information regarding Part A coverage is available, the Railroad Retirement Board will send the Part B claim, together with pertinent information regarding the Part A determination, to P almetto Government Benefits for consideration of whether the other requirements for Part B coverage are met, and further processing.  350.8 - Claims from Hospital -Leased Laboratories Not Meeting Conditions of Participation  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)
(Medicare Claims Processing Manual)
Services furnished by a laboratory that does not meet the hospital laboratory conditions of participation and is operated under a lease arrangement in a domestic emergency hospital are covered only if they are emergency inpatient services reimbursable under Part A.  A MAC may send a claim from such a laboratory and identify it as an "Emergency Lead."  The MAC checks its files to see if a claim for emergency services was filed and, if so, determines whether the laboratory services were furnished during the period of em ergency.  If the emergency claim was forwarded to the appropriate MAC for processing, it enters the date received on the laboratory claim.   If no emergency claim was filed, or laboratory services were not furnished in the period covered by the emergency claim, the MAC develops the claim as a possible emergency.  It includes the laboratory claim with any subsequent claim.   If no emergency is alleged, the MAC records on the claim that no emergency existed and disallows it.  350.9 - Nonemergency Part B Medical and Other Health Services  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  A.  Coverage   Nonemergency services to Medicare beneficiaries may be paid for if the coverage requirements for the services are met, and are not covered as Part A emergency inpatient services.   Program payment may be made for the following Part B medical and other health services furnished by a U.S. nonparticipating hospital on a nonemergency basis:    Diagnostic x- ray tests, diagnostic laboratory tests and other diagnostic tests.  (The hospital must meet the applicable conditions of participation for the services.)    X-ray, radium, and radioactive isotope therapy, including materials and services of technicians.  (The hospital must meet the applicable conditions of participation for these services.)    Services of residents and interns, nurses, therapists, etc., which are directly related to the provision of x- ray or laboratory or other diagnostic tests, or the provisions of x- ray or radium therapy.    Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue) or replace all or part of the functions of a permanently inoperative or malfunctioning internal body organ, including replacement of such devices.
(Medicare Claims Processing Manual)
 Leg, arm, back, and neck braces, trusses and artificial legs, arms, and eyes, including replacement, if required, because of a change in the patient's physical condition.  B.  Distinction Between Emergency and Nonemergency Medical and Other Health Services   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
(Medicare Claims Processing Manual)
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);
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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.