Under the guarantee of payment provision, a participating hospital may be paid for
inpatient hospital services furnished on behalf of a beneficiary whose benefit days
have been exhausted (including the 190-day lifetime limit on inpatient psychiatric
hospital services). The guarantee of payment provision does not apply until the individual
has exhausted his 60 lifetime reserve days except where the average daily charge is equal to, or less than the lifetime reserve day
coinsurance amount, since in such cases the reserve days cannot be used by the beneficiary.
(See HI 00601.065).
The guarantee applies only to inpatient hospital services furnished by a participating
hospital, whether general, psychiatric, or tuberculosis. The provision assures that
payment will be made to a hospital for services furnished during the time it takes
to ascertain the patient’s eligibility from the utilization record.
Benefits are payable under the guarantee if the patient’s benefit days were exhausted
before the intermediary’s reply to the notice of admission reached the hospital. This
includes those situations in which benefit days were exhausted prior to admission
and where a beneficiary had some benefit days remaining at the time of his admission,
e.g., two or three days of eligibility, but these were exhausted before the intermediary’s
reply to the notice of admission reached the hospital. Payment under the guarantee
is made at the full rate; that is, the hospital receives payment without any reduction
for coinsurance. A hospital is not required to claim payment under the guarantee provision;
it may look to the patient for payment.