A beneficiary who believes that a high-cost provider’s charge for services is unwarranted
because the services constitute emergency services files their protest with the provider.
If the beneficiary telephones their protest to the DO, they should be referred to
the provider. If the beneficiary makes their protest in person, obtain their statement
on an SSA-795, explaining why the beneficiary thinks the services were emergency services.
Forward a copy of the SSA-795 to the hospital for necessary action, and send the original
to the CMS RO as a control.
Unless the hospital concedes that the services in question were furnished in the most
accessible hospital, the CMS RO may call upon the DO to complete an HCFA-1771A by
contact with the hospital. The references to “participating hospital” and “nonparticipating hospital” should be changed to “hospital which makes no charges for excess cost” and “hospital which charges for excess cost” respectively.
Where a beneficiary complains that an excess cost provider is charging more than the
allowable excess costs, there is no appeal available. However, forward any such complaint
to the CMS RO to resolve the issue. It will find either that the beneficiary is mistaken
and provide them with an explanation; or, if the provider is wrong, assure that it
rectifies its actions.