A beneficiary who believes that a high-cost provider’s charge for services is unwarranted
because the services constitute emergency services files his protest with the provider.
If the beneficiary telephones his protest to the DO, he should be referred to the
provider. If he makes his protest in person, obtain his statement on an SSA-795, explaining
why he 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 him with an explanation; or, if the provider is wrong, assure that it
rectifies its actions.