HI 00601.610 Determining Emergency Services

A. Hospital actions

The hospital"s decision that its services were not emergency services will ordinarily be subject to review only if the decision is questioned by the beneficiary or his representative. If the decision is questioned, the hospital obtains a written statement from the beneficiary as to why he thinks the services were emergency services and has the attending physician complete an CMS-1771. Attending Physician"s Statement and Documentation of Medicare Emergency. (Change the reference to “participating hospital” or “hospital which participates under the Medicare program” to “hospital which makes no charges for excess costs”.) A copy of the patient"s hospital records, including a minimum history, physical examination, doctor"s orders, and all progress notes may be submitted in lieu of the CMS-1771. A statement that an emergency did not exist or the history or the diagnosis, without supporting information, is not sufficient. The statement concerning the character of the services is made by the physician attending the patient at the hospital. In exceptional situations, with an appropriate explanation showing justification, (e.g., the attending physician is dead) the certification may be made by another physician who has full knowledge of the circumstances at the time of admission.

The hospital forwards the beneficiary statement, the CMS-1771, or other evidence with a full explanation as to why it believes the services furnished were not emergency services through its intermediary to the CMS RO, with a request for a determination as to whether the services constitute emergency services.

B. Regional office action

The CMS RO reviews the evidence submitted by the hospital concerning the services in question and requests any necessary additional evidence. Unless the hospital has conceded that the services were furnished in the most accessible hospital, the regional office completes or has the DO complete an CMS-1771A (Emergency Services Accessibility Documentation and Determination) by personal or phone contact with the hospital.

As is the case in determining payment to nonparticipating hospital for emergency services, the CMS RO calls upon the Community Health Service (Public Health Service) regional office for assistance in evaluating the medical necessity of the case, including an accessibility determination if medical factors are involved.

The CMS RO sends the beneficiary a notice of its determination and a copy to the provider. If the services are found to be emergency services, the hospital must desist from further efforts to collect the charges and refund any amounts collected for them.

C. Regional office notices

When the CMS RO makes a determination, it notifies the beneficiary and the provider. The notice includes one of the following paragraphs.

1. Emergency services not involved

The medical facts related to the services you received have been carefully reviewed. Based on this review, we have found that no emergency existed which required immediate treatment by this hospital to prevent a threat to life or health. Therefore, the hospital was authorized to charge for the excess cost of the services.

2. Emergency services involved but other qualified provider available

The medical facts of your case have been carefully reviewed. Based on this review we have found that an emergency existed but that adequate treatment could have been provided in another hospital that does not impose charges for excess costs and was as accessible as the one in which you received care. Therefore, the hospital you used is authorized to make the charges described.

3. Emergency services involved other qualified provider not available

The medical facts related to the services you received have been carefully reviewed. Based on the review, we have found that an emergency existed which required immediate treatment by this hospital to prevent a threat to life or health. Therefore, the hospital is not free to charge you for the services and should refund any amount collected from you or any other person on such charges and we have so advised the hospital.

The Notices include the reconsideration filing time limit of 60 days.


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