CMS Pub. 100-04, ch. 32, § 360.3.2

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

REFER TO:

Identification Number:______________________

Dear ___________________:

Under the Medicare program, hospital benefits ordinarily can be paid only for care furnished to patients of hospitals that

are participating in the program. However, the program can also pay for hospital services furnished to a beneficiary who

is admitted to a nonparticipating hospital in an emergency. To receive payments for emergency services, a

nonparticipating hospital must meet certain conditions specified in the law. We have determined that your hospital

meets these conditions.

Payment for emergency services can be made to a nonparticipating hospital only if the hospital elects to receive

reimbursement from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year.

Although your hospital did not elect to bill the program for the current calendar year, you may wish to bill for the

coming year. If you so choose, please have an authorized official of your hospital sign a statement to this effect and

return in the enclosed self-addressed envelope. Retain a copy for your records. An election to bill cannot be withdrawn

during the year.

If we have not received a statement from you by December 31, we will assume that you do not wish to bill the program

at this time. However, you still retain the right to elect to bill the program at any time during the coming year if, when

you make your election, you have not yet charged any Medicare beneficiary in that year for emergency hospital services

rendered to him.

Hospitals electing to bill the program for emergency services may obtain information on reimbursement by contacting

us. If a hospital does not elect to bill, the beneficiary may apply for reimbursement by submitting an itemized bill.

If at any time you decide to request full participation as a provider of hospital services under the Medicare program,

please contact your Medicare intermediary for complete particulars.

Sincerely,