US · guidance
CMS Pub. 100-16, ch. mc86c17c, § 80
Emergency and Urgently Needed Provider Services, and Out of
Area Provider Services for Which the Cost-Based HMO/CMP Assumes
Financial Responsibility
(Rev. 4, 10-01-01)
The Medicare FFS system may pay the providers for the reasonable cost of covered
emergency or urgently needed services and other covered out of area services for which
the cost-based HMO/CMP assumes financial responsibility and which are furnished to
the HMO/CMP’s Medicare enrollees.
Alternatively, the HMO/CMP may reimburse a provider for these services, in which case
payment will be made to the HMO/CMP through the cost reporting mechanism.
However, payment to the HMO/CMP for such services is allowable only to the extent
that it does not exceed the reasonable cost for the service or Medicare’s prospective
payment for the service, as defined in 42 CFR, Parts 405, 412, and 413.
Exception:
Payment in excess of the amount allowed under 42 CFR, Parts 405, 412, and 413 may be
made if the HMO/CMP demonstrates to CMS’s satisfaction that the excess payment is
justified on the basis of advantages gained by the HMO/CMP. (See 42 CFR 417.558.)
History
(Rev. 4, 10-01-01)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
ca3bb27a9a9b9645f185f710b9c2cc0dd614200b30d6afb8531918aedc6e3a58
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