CMS Pub. 100-04, ch. 32, § 360.3.8

The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification

number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim

Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after

for certain business areas that will continue to use the HICN as part of their processes.

MODEL DENIAL

NOTICE (MAC’S NAME AND ADDRESS)

Date:

Beneficiary:

Claim Number:

DETERMINATION ON FOREIGN HOSPITAL SERVICES

We are sorry, but payment cannot be made for your stay

from through

at (hospital) in (country).

Medicare law prohibits payment for items and services furnished outside the United States except in certain limited

circumstances. The term “outside the U.S.” means anywhere other than the 50 states of the U.S., the District of

Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

There are three situations when Medicare may pay for certain types of health care services rendered in a foreign

hospital (a hospital outside the U.S.):

1. You’re in the U.S. when you have a medical emergency and the foreign hospital is closer than the nearest

U.S. hospital that can treat your illness or injury.

2. You’re traveling through Canada without unreasonable delay by the most direct route between Alaska and

another state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S.

hospital that can treat your illness or injury. Medicare determines what qualifies as “without unreasonable

delay” on a case-by-case basis.

3. You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can

treat your medical condition, regardless of whether it’s an emergency.

In these situations, Medicare will pay only for the Medicare-covered services you get in a foreign hospital.

If you have a supplemental insurance policy, you should check with the company carrying that policy to see if they

cover these services and what procedures you should follow in submitting your claim.

If you have questions about this notice, you may call 1-800-MEDICARE (1-800-633-4227) for additional information.

If you believe the determination is not correct, you may request a redetermination. You must file your request within

120 days from the date you receive this notice. A request for a redetermination must be filed either on Form CMS-

20027 or on a written request that includes all of the elements listed below.

• Beneficiary name

• Medicare beneficiary identifier

• Specific service and/or item(s) for which a redetermination is being requested

• Specific date(s) of service

• Signature of the beneficiary or the beneficiary’s authorized or appointed representative.

You may send the request to our address listed above. Please keep a copy of any written correspondence for your files.

Sincerely,