CMS Pub. 100-04, ch. 32, § 360.3.3

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

REFER TO:

Identification Number:______________________

Dear ____________________:

This refers to your inquiry concerning payment for emergency hospital services rendered to a Medicare beneficiary in a

hospital which is not participating in the Medicare program. 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 you elect to receive reimbursement

from Medicare for all emergency services furnished to Medicare beneficiaries in a calendar year. Your hospital may

now choose to bill the program for all emergency services furnished to Medicare beneficiaries during the current

calendar year, if you have not yet charged any Medicare beneficiary this year for emergency hospital services rendered

to him.

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 An election to bill cannot be withdrawn during the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.

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

us. If you do 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,