3. Payment limitation

Program payment can be made for up to 3 days of inpatient hospital or extended care services rendered following the date the institution receives notice of a finding by a UR committee that further inpatient services are not medically necessary. Effective with services rendered after December 31, 1972, this payment limit also extends to a finding by a UR committee, made during the course of a sample or other review of admissions, that admission to the hospital or SNF was not medically necessary. This provision is affected by the waiver of liability provision. Where it is determined that noncovered care was rendered prior to the UR committee's finding, the intermediary determines whether the waiver of liability provision applies before any payment can be made under 1. above.

Certain diagnostic tests needed in connection with a hospital admission that can be done either on an inpatient or outpatient basis may be paid for, under certain conditions, at 100 percent rather than the usual 80 percent if the tests are administered in the outpatient department of a hospital seven days before the patient's admission as a hospital inpatient. This provision may be extended to preadmission diagnostic tests done in a physician's office or on an outpatient basis in a hospital other than the hospital to which the patient is admitted, if found to be administratively practical.