CMS Pub. 100-04, ch. 32, § 350.10

A. Nonparticipating U.S. Hospitals

As a nonparticipating U.S. hospital meeting emergency requirements, the hospital has the option to bill the program

during a calendar year by filing an election with its MAC. If it files an election, it should submit claims for the

following services furnished all Medicare beneficiaries throughout the year:

• Emergency inpatient services; and

• Emergency outpatient services.

In addition, the hospital may not bill any beneficiary beyond deductibles, coinsurance, and noncovered services in that

calendar year. It must agree to refund any monies incorrectly collected. It may not file an election for the calendar year

if it has already charged any beneficiary for covered services furnished in that year.

If the hospital does not file a billing election, the beneficiary can file a claim. The beneficiary may request information

from the hospital or the MAC as appropriate.

During November of each year, the MAC will send the non-participating hospital a letter (see §360.3.1). Also, during

November of each year, the MAC will send a letter to each domestic hospital, giving it an opportunity to elect to bill

Medicare if it has not been doing so (§360.3.2).

If during the year the hospital requests to bill the program, its MAC will send the model letter in §360.3.3.

B. Billing for Services Furnished Prior to Certification

The following rules apply if a bill is submitted for services rendered before and after a hospital's certification

(participation) date:

• PPS hospitals are paid the DRG, if the date of discharge is after the certification date.

• Other hospitals are paid for services rendered after the certification date. However, the hospital must include

services before certification date on its cost report.

It should annotate in the upper right hand corner of the claim "Emergency Conversion."

C. Foreign Hospitals

Foreign hospitals may submit a statement to the appropriate MAC stating that they will bill for all claims. If they do not,

the beneficiary may claim the payment. When the MAC is aware that a hospital is willing to bill the program for all

covered services, it solicits the hospital's agreement to:

• Bill for all covered services for the calendar year (except for deductible and coinsurance amounts);

• Not bill the beneficiary for any amounts other than for deductible and coinsurance and charges for noncovered

services; and

• Refund to the beneficiary any monies incorrectly collected.

A hospital may not file an election for a calendar year if it has charged any beneficiary for covered services during that

year.

D. Submitting Claims

The beneficiary or the hospital that has elected to bill the program may submit emergency claims for payment to the

appropriate MAC for evaluation of accessibility or emergency factors.

The hospital completes the claim (Form CMS-1450 or electronic equivalent) according to billing instructions in chapter

25. It enters "hospital filed emergency admission" in Item 94 "Remarks." It sends the completed bill and the necessary

emergency documentation (Form CMS-1771, Attending Physicians Statement and Documentation of Medicare

Emergency) or medical records to substantiate the emergency to the appropriate MAC.

NOTE: See §360.2, "Designated Contractors."

If the hospital submits a claim but has not filed an election to bill the program, the MAC will contact the hospital to

determine if it is qualified and wish to bill the program. If it declines, the claim will be denied. A claim will be solicited

from the beneficiary.

If the hospital has filed a billing election and the beneficiary files a claim, the beneficiary's claim is denied and the MAC

contacts the hospital regarding the claim.