US · guidance
CMS Pub. 100-16, ch. 4, § 20.4
Stabilization of an Emergency Medical Condition
The physician treating the enrollee must decide when the enrollee may be considered
stabilized for transfer or discharge, and that decision is binding on the MAO. Refer to
section 20.5 below for the MAO’s obligations regarding services provided following
stabilization. Chapter 13 of the MMCM, “MA Beneficiary Grievances, Organization
Determinations, and Appeals,” addresses the enrollee’s right to request a Quality
Improvement Organization review of hospital discharges to a lower level of care. For
transfers from one inpatient setting to another inpatient setting, an enrollee or person
authorized to act on his or her behalf who disagrees with the decision and believes the
enrollee cannot safely be transferred may request that the organization pay for continued
out-of-network services. If the MAO declines to pay for the services, appeal rights are
available to the enrollee.
History
(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
199dd9d1016422c078005bf0050a9010c93d0001be1e8e42e1fd5dd6831826e3
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