Definition of Emergency Care Services and Appeals of Opt Out Determinations

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Definition of Emergency Care Services and Appeals of Opt Out Determinations

This Article is intended for physicians and practitioners who opt-out of Medicare, and beneficiaries that receive services from opt out physicians and practitioners.

Note: The private contracting regulation at 42 CFR 405.450 describes certain opt-out determinations made by Medicare, and the process that physicians, practitioners, and beneficiaries may use to appeal those determinations. The cross references to the processes used to appeal the determinations described in Section 405.450 were updated in the November 13, 2014 Federal Register (Volume 79, Number 219). The definition of Emergency care services at 42 CFR 405.400 was also corrected in that November 13, 2014
Federal Register.

Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and because of the danger to life or health, which require use of the most accessible hospital available that is equipped to furnish those services. Congress intended that the term “emergency or urgent care services” not be limited to emergency services since they also included “urgent care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an ear infection with significant pain, the Centers for Medicare & Medicaid Services (CMS) would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.

What You Need to Know- Be aware that a physician or practitioner who is dissatisfied with a Medicare determination under Section 405.450(a) may utilize the enrollment appeals process currently available for providers and suppliers in Part 498. Be aware that a determination described in Section 405.450(b) (that payment cannot be made to a beneficiary for services furnished by a physician or practitioner who has opted out) is an initial determination for the purposes of Section 405.924 and may be challenged through the existing claims appeals procedures in Part 405 subpart I. Be aware that emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.

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This Article is intended for physicians and practitioners who opt-out of Medicare, and beneficiaries that receive services from opt out physicians and practitioners.

Note: The private contracting regulation at 42 CFR 405.450 describes certain opt-out determinations made by Medicare, and the process that physicians, practitioners, and beneficiaries may use to appeal those determinations. The cross references to the processes used to appeal the determinations described in Section 405.450 were updated in the November 13, 2014 Federal Register (Volume 79, Number 219). The definition of Emergency care services at 42 CFR 405.400 was also corrected in that November 13, 2014
Federal Register.

Emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and because of the danger to life or health, which require use of the most accessible hospital available that is equipped to furnish those services. Congress intended that the term “emergency or urgent care services” not be limited to emergency services since they also included “urgent care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an ear infection with significant pain, the Centers for Medicare & Medicaid Services (CMS) would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.

What You Need to Know- Be aware that a physician or practitioner who is dissatisfied with a Medicare determination under Section 405.450(a) may utilize the enrollment appeals process currently available for providers and suppliers in Part 498. Be aware that a determination described in Section 405.450(b) (that payment cannot be made to a beneficiary for services furnished by a physician or practitioner who has opted out) is an initial determination for the purposes of Section 405.924 and may be challenged through the existing claims appeals procedures in Part 405 subpart I. Be aware that emergency care services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.

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