CMS Pub. 100-04, ch. 32, § 350.11

All claims are subject to development to determine whether the Medicare secondary payer provisions apply. (See Pub.

100-05, Medicare Secondary Payer Manual.)

A. Nonparticipating Hospitals

The processing MAC is responsible for making accessibility and medical emergency determinations for physician and

ambulance services.

1. Claims Subject to Technical Denials

The following claims are subject to technical denial:

• Foreign nonemergency services claims if:

° The residence requirement is not met. (See §350.5.)

° The hospital rendering the service does not meet Joint Commission or equivalent accreditation

requirements set by a hospital approval program of the country in which it is located.

° The accessibility requirements are not met. (See §350.11.4.)

• Canadian travel claims when the requirements in §350.4 are not met.

• Emergency services claims for which the hospital does not meet the definition of an emergency hospital.

• Claims for which the query response shows the beneficiary is not entitled to benefits.

• Any foreign claim when Part A benefits are exhausted and Part B physician or ambulance claims are not

involved.

2. Either the Accessibility or Medical Emergency Requirements are Not Met

Claim is denied but retained in case of an appeal by the beneficiary.

NOTE: Even though Part A or Part B emergency services furnished by U.S. hospitals are denied, Part B payment may

be possible for Medical and Other Health Services specified in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6.

Claim is retained in case of an appeal by the beneficiary.

3. Emergency Services Partially Denied

When the medical emergency is approved but not for the entire period, the claim is processed and payment made for the

covered period.

B. Foreign Part B Physician and Ambulance Claims

The hospital must attach any Part B claim for foreign physician and ambulance services to the corresponding Part A

claim and forward to the MAC.

If the MAC determines that the inpatient services were covered, it sends the physician and/or independent ambulance

claim to the designated MAC for processing and payment. (See §350.6.)

If the Part A claim is denied on the basis of accessibility of medical emergency, the MAC denies the Part B claim, and

sends a MSN to the beneficiary. It retains copies in case of an appeal by the beneficiary.

NOTE: Even though Part A benefits are totally or partially exhausted, payment may be made by the MAC for physician

and independent ambulance services furnished if all coverage requirements are met.

If a Part A claim was partially denied because the emergency terminated, the MAC makes a decision on the claim and

any provider-based ambulance claim. It sends copies to the appropriate MAC for processing.