A. Hospital actions

The hospital"s decision that its services were not emergency services will ordinarily be subject to review only if the decision is questioned by the beneficiary or the beneficiary's representative. If the decision is questioned, the hospital obtains a written statement from the beneficiary as to why the beneficiary thinks the services were emergency services and has the attending physician complete an CMS-1771. Attending Physician"s Statement and Documentation of Medicare Emergency. (Change the reference to “participating hospital” or “hospital which participates under the Medicare program” to “hospital which makes no charges for excess costs”.) A copy of the patient"s hospital records, including a minimum history, physical examination, doctor"s orders, and all progress notes may be submitted in lieu of the CMS-1771. A statement that an emergency did not exist or the history or the diagnosis, without supporting information, is not sufficient. The statement concerning the character of the services is made by the physician attending the patient at the hospital. In exceptional situations, with an appropriate explanation showing justification, (e.g., the attending physician is dead) the certification may be made by another physician who has full knowledge of the circumstances at the time of admission.

The hospital forwards the beneficiary statement, the CMS-1771, or other evidence with a full explanation as to why it believes the services furnished were not emergency services through its intermediary to the CMS RO, with a request for a determination as to whether the services constitute emergency services.