§ 405.152 Payment for services furnished; nonparticipating hospital furnishing emergency services.

(a) Payment (in amounts as determined in accordance with § 409.69) may be made to a hospital even though the hospital is not a participating provider (i.e., it has not entered into an agreement with the Secretary, pursuant to section 1866 of the Act and Part 489 of this chapter) if:

(1) The hospital meets the requirements of section 1861(e) (5) and (7) of the Act (see § 405.1001(a)), and:

(i) Is primarily engaged in providing under the supervision of a doctor of medicine or osteopathy the services described in section 1861(e)(1); and

(ii) Is not primarily engaged in providing the services described in section 1861(j)(1)(A) (see § 405.1101(a));

(2) The services furnished are emergency services (see paragraph (b) of this section) furnished an individual who is entitled to hospital insurance benefits;

(3) The services are furnished by the hospital or by others under an arrangement made by the hospital;

(4) The hospital agrees to comply, with respect to the services furnished, with the provisions of Part 489 of this chapter regarding the charges for such services which may be imposed on the individual or any other person, and the return of any money incorrectly collected;

(5) With respect to services furnished in a calendar year beginning after December 31, 1967, the hospital has in effect an election to claim payment for all emergency services furnished in such calendar year (see § 405.658);

(6) Written request for payment is filed by, or on behalf of the individual to whom such services were furnished;

(7) Payment for the services would have been made if an agreement under Part 489 of this chapter had been in effect with the hospital and the hospital otherwise met the conditions for payment;

(8) The hospital's claim for payment is filed with the Health Care Financing Administration and is accompanied (attached thereto or as part thereof) by a physician's statement describing the nature of the emergency and stat

ing that the emergency services rendered were necessary to prevent the death of the individual or the serious impairment of his health. The statement must be sufficiently comprehensive to support a finding (see § 405.191) that an emergency existed. Where the hospital files a second or subsequent claim with respect to such emergency situation, such second or subsequent claim must be accompanied by a physician's statement containing sufficient information to indicate clearly that the emergency situation still existed. When inpatient hospital services are involved, an initial or subsequent physician's statement (as appropriate) must include the date when, in the physician's judgment, the emergency ceased.

(b) For purposes of the hospital insurance benefits program, "emergency services" are those inpatient hospital services which are necessary to prevent the death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible hospital (see § 405.192) available and equipped to furnish such services.

[34 FR 11206, July 3, 1969, as amended at 37 FR 21163, Oct. 6, 1972. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 4429, Feb. 2, 1978; 50 FR 33030, Aug. 16, 1985]

§ 405.153 Payment for services; hospital outside the United States.

(a) Emergency services. The authority contained in § 405.152 is applicable to emergency inpatient hospital services furnished an individual by a hospital located outside the United States if:

(1) The individual was physically present in a place within the United States or, effective with admissions occurring after December 31, 1972, at a place within Canada while traveling without unreasonable delay by the most direct route between Alaska and another State, at the time the emergency arose which necessitated such inpatient hospital services; and

(2) The hospital was closer to, or substantially more accessible from, such place than the nearest hospital

(b) Services in hospital which is closest to or most accessible from beneficiary's residence. Effective with admissions occurring after December 31, 1972, payment shall be made for inpatient hospital services furnished an individual entitled to hospital insurance benefits under section 226 of the Social Security Act, by a hospital located outside the United States, or under arrangements (as defined in section 1861(w) of the Social Security Act) if:

(1) Such individual is a resident of the United States; and

(2) Such hospital was closer to, or substantially more accessible from the residence of such individual than the nearest hospital within the United States which was adequately equipped to deal with, and was available for the treatment of, such individual's illness or injury; and

(3) The foreign hospital is (i) a hospital as defined in § 405.152(a)(1) and (ii) is accredited by the Joint Commission on Accreditation of Hospitals, or is accredited or approved by a program of the country in which such institution is located if the Health Care Financing Administration finds the accreditation or comparable approval standards of such program to be essentially equivalent to those of the Joint Commission on Accreditation of Hospitals.

(c) Payments. (1) Payment to a Canadian or Mexican hospital for inpatient services specified in paragraphs (a) and (b) of this section and furnished either directly by the hospital, or under arrangements made by the hospital, shall be made in the amount specified in § 405.456, if:

(i) Payment would be made if a provider agreement were in effect with the hospital;

(ii) The hospital files a statement of election to claim payment for all covered services furnished during a calendar year (see § 405.658); and

(iii) The hospital agrees to comply with those terms of a provider agree

ment that relate to charges and refunds to patients, as specified in § 405.607.

(2) If the foreign hospital does not file an election to claim direct payment from the Medicare program for covered inpatient services furnished to a Medicare beneficiary, payment will be made to the beneficiary based on an itemized bill of the hospital. In accordance with sections 1814(d)(3) and 1814(f)(4) of the Act, the payment amount, which is subject to the applicable deductible and coinsurance amounts, shall be equal to the following:

(i) If the hospital makes separate charges for routine and ancillary services, 60 percent of the hospital's reasonable charges for routine services furnished in the accommodations occupied by the Medicare beneficiary or in semiprivate accommodations, whichever is less, and 80 percent of the reasonable charges for ancillary services for covered days in the benefit period.

(ii) If the hospital does not make separate charges for routine and ancillary services, two-thirds of the hospital's reasonable charges for all covered services furnished in the benefit period, but not to exceed charges based on semiprivate accommodations. (Secs. 1102, 1814 (b), (d), and (f), 1861(v), and 1871 of the Social Security Act; (42 U.S.C. 1302, 1395f (b), (d), and (f), 1395x(v), and 1395hh))

[39 FR 1750, Jan. 14, 1974. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 44 FR 67382, Nov. 26, 1979]

§ 405.157 Payment to entitled individual for emergency services furnished after 1967.

An individual entitled to hospital insurance benefits may receive payment on the basis of an itemized hospital bill (see § 405.158) for inpatient hospital services furnished with respect to an admission to the hospital on or after January 1, 1968, if:

(a) The services are furnished by a nonparticipating hospital and would otherwise constitute emergency services for which payment may be made under the provisions of § 405.152, if such hospital had filed, and the Social

Security Administration or the Health Care Financing Administration had accepted, the hospital's election to claim payment for all such emergency services; and

(b) Written application for payment is filed with the Social Security Administration or the Health Care Financing Administration by, or on behalf of, the individual to whom the services were furnished.

[34 FR 11206, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 4429, Feb. 2, 1978; 50 FR 33030, Aug. 16, 1985]

§ 405.158 Payment to entitled individual; determination of amount payable for services furnished by a nonparticipating hospital.

(a) Inpatient hospital services. (1) The amount payable to any individual with respect to payment under this Subpart A for inpatient hospital services (including emergency inpatient services) furnished by a nonparticipating hospital (see §§ 405.156 and 405.157) is, subject to the provisions of §§ 409.80, 409.82, 409.83, and 409.87 of this chapter for reducing such payment, equal to 60 percent of the hospital's reasonable charges for routine services furnished in accommodations occupied by the individual, or in accommodations containing from two to four beds, whichever is less; plus

(2) 80 percent of the reasonable charges for ancillary services. If the hospital does not make separate charges for such routine and ancillary services, payment (subject to the applicable deductions) will be equal to two-thirds of the hospital's reasonable charges for the inpatient services received, not to exceed charges based on accommodations containing from two to four beds.

(b) [Reserved]

(c) Routine and ancillary services, defined. For purposes of this section the term "routine services" means the regular room, dietary and nursing services, minor medical and surgical supplies, and the use of equipment and facilities for which a separate charge is not customarily made. Charges for two to four bed accommodations or the accommodations occupied, whichever is less, will be the

basis for the routine charges allowed. The term "ancillary services" means those covered special services for which charges are customarily made over and above those for routine services.

[34 FR 11207, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 43 FR 4429, Feb. 2, 1978; 50 FR 33030, Aug. 16, 1985]

§ 405.160 Payment to participating hospital for inpatient hospital services; conditions for payment.

(a) Inpatient hospital services. Payment may be made to a participating hospital for inpatient hospital services (other than inpatient psychiatric or tuberculosis hospital services) furnished an individual if:

(1) Written request for payment is filed by, or on behalf of the individual to whom the services were furnished;

(2) When required, a physician (other than a doctor of podiatry or surgical chiropody) certifies and recertifies (see Subpart P of this part) that such inpatient hospital services were required to be given on an inpatient basis for the individual's medical treatment, or that inpatient diagnostic study was medically required and the services were necessary for such purpose; and

(3) The conditions prohibiting payment, described in §§ 405.162 and 405.163, are not applicable.

(b) Inpatient psychiatric hospital services. Payment may be made to a participating hospital for inpatient psychiatric hospital services furnished an individual if:

(1) Written request for payment is filed by or on behalf of the individual to whom the services were furnished;

(2) When required, a physician (other than a doctor of podiatry or surgical chiropody) certifies and recertifies (see Subpart P of this part) that such inpatient psychiatric hospital services were required to be given on an inpatient basis, by or under the supervision of a physician, for the psychiatric treatment of the individual, and

(i) That such treatment could reasonably be expected to improve the

conditions for which such treatment was necessary; or

(ii) That inpatient diagnostic study was medically required and such services were necessary for such purposes;

(3) The services are those which the records of the hospital indicate were furnished to the individual during periods when he was receiving intensive treatment, services, admission and related services necessary for a diagnostic study, or equivalent services; and

(4) The conditions prohibiting payment, described in §§ 405.162 and 405.163 are not applicable.

(c) Inpatient tuberculosis hospital services. Payment may be made to a participating hospital for inpatient tuberculosis hospital services furnished an individual if:

(1) Written request for such payment is filed by or on behalf of the individual to whom the services were furnished;

(2) When required, a physician (other than a doctor of podiatry or surgical chiropody) certifies and recertifies (see Subpart P of this part), that such services were required to be given on an inpatient basis, by or under the supervision of a physician, for the treatment of tuberculosis and such treatment could reasonably be expected to improve the condition or render the condition noncommunicable;

(3) The services are those which the records of the hospital indicate were furnished to the individual during periods when he was receiving treatment which could reasonably be expected to improve his condition or render it noncommunicable; and

(4) The conditions prohibiting payment described in §§ 405.162 and 405.163 are not applicable.

(d) Correlation of PSRO-Medicare certification requirements. If a Professional Standards Review Organization (PSRO) has assumed review responsibility in accordance with the applicable provisions of Part 463 of this chapter for the inpatient services provided by or in the hospital, a certification made by the attending physician under section 1156(d) of the Act shall be in lieu of the physician's certification required under paragraphs (a), (b), and (c) of this section. However, the coverage requirements of §§ 409.10

through 409.18, to which the physician would otherwise certify, continue to apply to payment determinations for the services. (See §§ 463.25, 463.26, and 463.28 for provisions concerning the correlation of functions under titles XI-B and XVIII of the Act.

[31 FR 10121, July 27, 1966, as amended at 34 FR 11207, July 3, 1969. Redesignated at 42 FR 52826, Sept. 30, 1977, and amended at 44 FR 16396, Mar. 19, 1979; 50 FR 33030, Aug. 16, 1985]

§ 405.162 Prohibition against payment for inpatient hospital services furnished after utilization review finding that further services are not medically necessary.

(a) Hospital system of utilization review. If a finding has been made under a hospital system of utilization review (see §§ 405.1035 and 405.1042) that further inpatient hospital services are not medically necessary, payment may be made only for those inpatient hospital services furnished before the fourth day following the day on which the hospital received notice of the finding.

(b) PSRO and PRO system of review. If a Professional Standards Review Organization (PSRO) or a Utilization and Quality Control Peer Review Organization (PRO) has assumed review responsibility in accordance with the applicable provisions of § 405.472 and of Part 463 of this chapter for the inpatient hospital services furnished by or in the hospital, the payment limitation described in § 463.17(a) applies to the inpatient hospital services furnished to a beneficiary and shall be in lieu of the payment limitation in paragraph (a) of this section.

(c) If a hospital is paid for inpatient hospital services under the prospective payment system established by §§ 405.470 through 405.477, the payment limitation in paragraph (a) of this section applies only in cases otherwise eligible for outlier payment under $405.475 if the utilization review committee determines that: (1) Excess days of care furnished in the case of a length of stay outlier are not necessary to furnish services covered under Medicare Part A; or

(2) Additional items and services furnished in the case of a high cost outlier are either not covered or not necessary to furnish services covered under Medicare Part A.

[48 FR 39807, Sept. 1, 1983]

§ 405.163 Prohibition against payment for inpatient hospital services furnished after 20th consecutive day by a hospital which has failed to make timely utilization review.

(a) When HCFA has determined that a hospital has substantially failed to make timely utilization review in long stay cases and has imposed the limitation on days of services provided in section 1866(d), no payment may be made under this Subpart A for inpatient hospital insurance services furnished by such hospital to any individual after the 20th consecutive day on which such services have been furnished to him if the individual is admitted after the effective date of such determination.

(b) HCFA will not make a finding of failure to make timely utilization review, as described in paragraph (a) of this section, that would have the effect of altering prospective payment amounts determined under §§ 405.473, 405.474, and 405.476.

[48 FR 39807, Sept. 1, 1983]

§ 405.165 Payment for posthospital SNF

care.

Medicare Part A pays for posthospital SNF care furnished in a SNF or a participating hospital that has a swing-bed approval if the following requirements are met:

(a) Request for payment. A written request for payment is filed by or on behalf of the individual to whom the services were furnished.

(b) Physician certification. A physician provides certification and recertification in accordance with § 405.1632.

(c) Other requirements. (1) The conditions for coverage set forth in §§ 409.20 and 409.30 through 409.36 of this chapter are met.

(2) Payment is not prohibited under §§ 405.166 and 405.167.

[50 FR 33030, Aug. 16, 1985]

§ 405.166 Prohibition against payment for posthospital SNF care after a utilization review finding that further care is not medically necessary.

(a) SNF system of utilization review (UR). If a finding has been made, under a SNF UR system required by § 405.1137, that further posthospital SNF care is not medically necessary, payment may be made only for care furnished before the fourth day following the day the SNF received notice of the finding.

(b) PRO system of review. If a PRO has assumed review responsibility and has found that further SNF care is not medically necessary, or should be furnished more economically or on an outpatient basis or in an inpatient facility of a different type, payment may be made for up to two days after the SNF receives notice of the PRO finding, but only if—

(1) The PRO has determined that additional time is required to arrange for post-discharge care; and

(2) It is determined, under § 405.332, that the SNF did not know, and could not reasonably have been expected to know that Medicare payment would not be made.

[50 FR 33030, Aug. 16, 1985]

§ 405.167 Prohibition against payment for posthospital SNF care furnished by a facility that fails to make timely utilization review (UR).

(a) Determination and notice. If HCFA determines that the facility has failed substantially to make timely UR of long-stay cases, it will notify the SNF and any hospital with which the SNF has a transfer agreement (or the hospital that has a swing-bed approval) and the public, that payment to the facility will be limited, and specify the effective date of the determination.

(b) Limitation on payment. Payment may not be made for SNF care furnished after the 20th consecutive day of care furnished to an individual admitted to the facility after the effective date of HCFA's determination. [50 FR 33030, Aug. 16, 1985]