CMS Pub. 100-02, ch. 1, § 10.1.1

A3-3101.1.A, HO-210.1.A

The program will pay the same amount for routine accommodations services whether the

patient has a private room not medically necessary, a private room medically necessary

(Medicare does not pay for deluxe accommodations in any case), a semiprivate room (2-,

3-, or 4-bed accommodations), or ward accommodations, if its ward accommodations are

consistent with program purposes (see §10.1.6 below).

A provider having both private and semiprivate accommodations may nevertheless

charge the patient a differential for a private room if:

• The private room is not medically necessary; and

• The patient (or relative or other person acting on their behalf) has requested the

private room, and the provider informs them of the amount of charge at the time

of the request.

The private room differential may not exceed the difference between the customary

charge for the accommodations furnished and the most prevalent semiprivate

accommodation rate at the time of the patient's admission.

Where the provider bills for a private room as a covered service, i.e., shows the charge

for the room as a covered charge on the Form CMS-1450, the A/B MAC (A) will deem

the private room to be medically necessary. Where the provider, on the other hand,

shows a private differential as a noncovered charge, the A/B MAC (A) will assume that

the private room is not medically necessary.

If the beneficiary (or their representative) protests a charge for the private room on the

grounds that the privacy was medically necessary, such protest will, if not in written

form, be reduced to writing and forwarded to the A/B MAC (A). The A/B MAC (A) will

then develop the facts and make a specific determination regarding the medical necessity

of the private room. (If an A/B MAC (A) receives many protests of this kind, the

provider may need guidance on what constitutes medical necessity for privacy). If the

protest is received after the claim is processed, it will be treated as a request for

reconsideration.

If at any time in the course of development (or thereafter within the period when the

determination is not administratively final), the provider acknowledges that the private

room was medically necessary; the A/B MAC (A) will make an immediate finding to this

effect.

Where it is necessary to develop the medical necessity of a private room, the guidelines

in subsections §§10.1.2 and 10.1.3 below will apply.