HI 00610.350 Payment for Medical and Other Health Services Furnished by Hospitals and SNF's

A. Part B services furnished to patients of nonparticipating SNF'S

Payment can be made under Part B for medical and other health services (see D. below) when furnished to patients of nonparticipating SNF's. Payment can be made to the non-participating SNF, another supplier or the beneficiary.

B. Part B services furnished to patients of nonparticipating hospitals

Payment may be made under Part B for those services (see D. below) furnished to patients of nonparticipating hospitals.

Where services are rendered and billed to the patient by a supplier, payment will be made to the supplier (on the basis of assignment) or to the beneficiary (on the basis of an itemized bill).

C. Part B services furnished to patients of participating institutions

Payment may be made under Part B for covered services furnished on or after April 1, 1968, by a participating institution (either directly or under an arrangement) or by a supplier to an inpatient of a participating hospital or SNF if payment for these services cannot be made under Part A. This could occur where the beneficiary has exhausted his allowed days of inpatient hospital or SNF coverage (or has elected not to use his lifetime reserve days) in his current benefit period, or there is otherwise no Part A coverage (e.g., an SNF patient who does not meet the prior hospital stay requirement), or the participating institution does not furnish the service to its inpatients either directly or under arrangements.

Reimbursement may be made to a supplier (on the basis of assignment) or to the beneficiary (on the basis of an itemized bill) for covered services furnished on or after April 1, 1968, to inpatients of participating institutions. Payment may be made for such services when they are billed to the patient by the supplier, even though the institution may at the same time be receiving Part A payments for other services furnished to the beneficiary.

For hospital outpatient services, see HI 00610.360.

D. Part B services reimbursable when furnished by providers or suppliers

Payment may be made for the following medical and other health services when furnished by a nonparticipating provider or by a supplier to patients of nonparticipating institutions (including institutions which do not meet the definition of an “emergency” hospital). Similarly, such paymetn may be made for such services furnished on or after April 1, 1968, to patients of participating institutions when they are not eligible for Part A benefits (see C. above).

  1. diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests (an institution furnishing these services must meet the hospital conditions of participation applicable to such services);

  2. X-ray, radium, and radioative isotope therapy, including materials and services of technicians (an institution furnishing these services must meet the hospital conditions of participation applicable to such services);

  3. services of residents and interns, nurses, therapists, etc., which are directly related to the provision of diagnostic X-ray or laboratory or other diagnostic tests, or the provisions of x-ray or radium therapy.

  4. surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;

  5. prosthetic devices other than dental which replace all or part of an internal body organ, including replacement of such devices; and

  6. leg, arm, back and neck braces, and artificial arms, legs, and eyes, including replacements therefor.

In addition the rental or purchase of durable medical equipment for use in the patient's home or in an institution which can be considered his home may be covered. (See HI 00610.190 for instructions relating to durable medical equipment and the definition of a beneficiary's home.)

Payments cannot be made to a nonparticipating SNF for the services listed in 1.-3. above except for diagnostic laboratory services unless the SNF bills for these services as an approved independent laboratory, and for portable X-ray services furnished in a setting which meets the definition of the beneficiary's home if the SNF bills for these services as a supplier of such services.

Payment may also be made for outpatient physical therapy and speech pathology services furnished by a participating provider of services. (See HI 00610.370)