CMS Pub. 100-02, ch. 15, § 40.29

Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death

or serious impairment of health and, because of the danger to life or health, require use of the most

accessible hospital available and equipped to furnish those services. Congress intended that the term

“emergency or urgent care services” not be limited to emergency services since they also included “urgent

care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours

in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an

ear infection with significant pain, CMS would view that as requiring treatment to avoid the adverse

consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the

definition of emergency medical condition because immediate care is not needed to avoid placing the

health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However,

although it does not meet the definition of emergency care, the beneficiary needs care within a relatively

short period of time (which CMS defines as 12 hours) to avoid adverse consequences, and the beneficiary

may not be able to find another physician or practitioner to provide treatment within 12 hours.