Medicare Fee-For-Service Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers
Summary
CMS question-and-answer document titled Medicare Fee-For-Service Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers, Version 13, dated 08/11/2023. The note states that the Q&As address matters that could potentially be the subject of or be affected without a declaration of the Stafford Act, or a Public Health Emergency of Section 1135 of the Social Security Act, and identify policies that may be available when the section 1135 waiver authority is not invoked. The contents list sections A through Y, including Flexibilities Available in the Event of an Emergency or Disaster, Physician Services, Ambulance Services, Home Health Services, Hospital Services and Medicare FFS Appeals. Question A-1 states that there is no authority for Medicare fee-for-service to make additional or special payments for emergency or disaster relief.
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“Medicare Fee-For-Service Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers.”
Original at www.cms.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/ppr-int-728716a9cdd301e4-without-1135-waivers-pdf-faa771c232-581b5ea6d2/
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Medicare Fee-For-Service
Emergency-Related Policies and Procedures
That May Be Implemented Without § 1135 Waivers
NOTE: The following Q&As address matters that, in the event of a disaster or emergency, could potentially be the
subject of or be affected without a declaration of the Stafford Act, or a Public Health Emergency (PHE) of Section 1135 of
the Social Security Act (the Act).
In the following Q&As, CMS identifies policies and procedures that may be available during a disaster or emergency
when the section 1135 waiver authority is NOT invoked. See the Q&As in Section B – Waiver of Certain Medicare
Requirements for information concerning making requests for waivers or modifications under the Section 1135
authority.
Contents
A - Flexibilities Available in the Event of an Emergency or Disaster .................................................................................... 2
B - Waiver of Certain Medicare Requirements .................................................................................................................... 3
C – General Payment Policies .............................................................................................................................................. 4
D – General Billing Procedures ............................................................................................................................................ 5
E – Physician Services .......................................................................................................................................................... 6
F – Ambulance Services ....................................................................................................................................................... 7
G – Laboratory & Other Diagnostic Services...................................................................................................................... 10
H – Drugs & Vaccines Under Part B ................................................................................................................................... 10
I – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) ............................................................. 12
J – End Stage Renal Disease (ESRD) Facility Services ......................................................................................................... 15
K – Home Health Services .................................................................................................................................................. 16
L – Hospice Services ........................................................................................................................................................... 18
M – Hospital Services – General ........................................................................................................................................ 21
N – Hospital Services – Emergency Medical Treatment and Labor Act (EMTALA) ............................................................ 25
O – Hospital Services – Acute Care .................................................................................................................................... 27
P – Hospital Services – Critical Access Hospitals (CAHS) .................................................................................................... 28
Q – Hospital Services – Inpatient Rehabilitation Facilities (IRFs) ....................................................................................... 28
R – Hospital Services – Long Term Care Hospitals (LTCHs) ................................................................................................ 28
S – Hospital Services – Mobile Emergency Hospitals ......................................................................................................... 29
T – Skilled Nursing Facilities (SNFs) .................................................................................................................................... 29
U – Mental Health Counseling ........................................................................................................................................... 32
V – Rural Health Clinics (RHCs)/ Federally Qualified Health Clinics (FQHCs) ..................................................................... 33
W – Fee-for-Service (FFS) Administration .......................................................................................................................... 33
X – Financial Management Policies ................................................................................................................................... 33
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Y – Medicare FFS Appeals .................................................................................................................................................. 36
ALL EMERGENCIES
A - Flexibilities Available in the Event of an Emergency or Disaster
Question Question and Answer
Number
A-1 Question: In the event of an emergency or disaster, what financial relief is available to providers, physicians
and other suppliers, and/or beneficiaries under the Medicare fee-for service program?
Answer: Currently, there is no authority for the Medicare fee-for service program to make additional or
special payments for the purpose of emergency or disaster relief. Even in the circumstance of a disaster or
emergency, Medicare fee-for-service is limited to making payments only for services covered under Medicare
Parts A & B that are furnished to Medicare beneficiaries in accordance with program rules. That said,
Medicare can make certain non-monetary adjustments in response to a disaster or emergency to ease
administrative burden on providers and on physicians and other suppliers and to enhance access to services
by Medicare beneficiaries even in the absence of waivers issued pursuant to section 1135 of the Social
Security Act (Act).
A-2 Question: What are the adjustments that Medicare fee-for-service can make in the event of an emergency or
disaster?
Answer: Broadly speaking, Medicare fee-for-service has three sets of potential temporary adjustments that
can be made to address an emergency or disaster situation. These include:
1. applying flexibilities that are already available under normal business rules;
2. waiver or modification of policy or procedural norms by the Administrator of the Center for Medicare
and Medicaid Services (CMS) under his or her authority; and
3. waiver or modification of certain Medicare requirements pursuant to waiver authority under § 1135
of the Social Security Act. This waiver authority can be invoked by the Secretary of the Department
of Health and Human Services (DHHS) in certain circumstances.
A-3 Question: The previous answer referred to “potential temporary adjustments”. Aren’t these adjustments
always implemented in the event of a disaster or emergency?
Answer: No, not always. First, each emergency or disaster is unique and creates specific, and sometimes
unique, challenges. Thus, the nature of the emergency or disaster will determine whether a particular
adjustment is appropriate (or even authorized). Second, CMS will usually tailor its response to specific,
identified needs that are communicated by or through State officials or health industry representatives in the
affected area and, in some cases, only when supported by documentation of need. Third, a waiver or
modification of requirements pursuant to § 1135 of the Social Security Act requires not only that the
Secretary of DHHS specifically invoke that authority, but also that certain conditions are met first – namely,
that there has been both a declaration by the Secretary of a public health emergency under Section 319 of
the Public Health Service Act and a declaration by the President of a disaster or emergency under the Stafford
Act or National Emergencies Act.
A-4 Question: Assuming that some level of response is forthcoming from Medicare fee-for-service in an
emergency or disaster, what, specifically, do these emergency/disaster-related adjustments include?
Answer: The questions and answers in this series, which are generally organized by benefit category or
provider type, describe specific adjustments/responses and whether the emergency/disaster response is
based on normal business rules, an adjustment within CMS’ discretion, or an adjustment that can be made
only under a § 1135 waiver. Please refer to or policies regarding the specific benefit category or provider
type related to the particular question.
A-5 Question: How will the healthcare community know what adjustments are available from Medicare fee-for-
service in a particular emergency or disaster?
Answer: The contractors that process Medicare fee-for-service claims (Medicare Administrative Contractors
(MAC), Durable Medical Equipment (DME) MACs, Regional Home Health Intermediaries (RHHI), and Carriers),
will implement Medicare fee-for-service adjustments based on instructions from CMS. In the event of an
emergency or disaster, providers and physicians and other suppliers should contact their servicing contractor.
The DHHS Regional Office(s) for the affected area(s) will generally serve as the point of contact for State
officials and industry associations. To raise an issue not addressed within these Q&As, send your query to
emergency.ops@cms.hhs.gov.
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B - Waiver of Certain Medicare Requirements
Question Question and Answer
Number
B-1 Question: What are “waivers” under § 1135 of the Social Security Act; how are they established; and how
do they apply to Medicare fee-for-service?
Answer: Section 1135 of the Social Security Act authorizes the Secretary of the Department of Health and
Human Services to waive or modify certain Medicare, Medicaid, CHIP, and HIPAA requirements. Two
prerequisites must be met before the Secretary may invoke the § 1135 waiver authority. First, the President
must have declared an emergency or disaster under either the Stafford Act or the National Emergencies Act.
Second, the Secretary must have declared a Public Health Emergency (PHE) under Section 319 of the Public
Health Service Act. Then, with respect to the geographic area(s) and time periods provided for in those
declarations, the Secretary may elect to authorize waivers/modifications of one or more of the requirements
described in Section 1135(b) and summarized below. The implementation of such waivers or modifications is
typically delegated to the Administrator of CMS who, in turn, determines whether and the extent to which
sufficient grounds exist for waiving such requirements with respect to a particular provider, or to a group or
class of providers, or to a geographic area.
Waivers authorized by the statute apply to Medicare in the context of the following requirements:
• conditions of participation or other certification requirements applicable to providers;
• sanctions for violations of certain emergency medical standards under the Emergency
Medical Treatment and Labor Act (EMTALA)
• sanctions for violations of the physician self-referral law (commonly referred to as the
“Stark Law”);
• performance deadlines and timetables (modifiable only; not waivable);
• certain payment limitations under the Medicare Advantage program; and
Medicare fee-for-service requirements, including most particularly (but not limited to) Medicare payment rules
and amounts, are generally not waived under § 1135. Nevertheless, some of the foregoing waivers, when
invoked, may have the effect of making fee-for-service payments possible when, absent a waiver, such
payments would not have been permissible.
B-2 Question: Does the § 1135 authority allow CMS to waive Medicare requirements that apply to individual
beneficiaries affected by the emergency/disaster? If so, would there be a set period of time for the
emergency to exist, or would such waiver vary by affected individual?
Answer: Section § 1135 waivers – when authorized – apply to requirements that apply to health care
providers. Such waivers do not directly apply to individual beneficiaries. However, the waivers that are
granted for health care providers are intended to reduce administrative burdens on those providers and to
increase flexibilities in the delivery of health care with the intent of promoting greater access to care by
individuals affected by the emergency or disaster.
B-3 Question: Will CMS provide disaster relief funding to hospitals following an emergency or disaster to make
up for any lost reimbursement? If so, what documentation will be required in patient clinical and financial
records?
Answer: There is no authority for CMS to provide special emergency/disaster relief funding following an
emergency or disaster in order to compensate providers for lost reimbursement. Medicare does not provide
funding for financial losses except as otherwise specified in existing regulations.
B-4 Question: How does a health care provider affected by an emergency request and receive approval for an
1135 waiver?
Answer: Section 1135 waivers are generally authorized for geographic areas for the duration of a declared
emergency or disaster. To determine whether waiver authority has been invoked for a particular emergency
or disaster and, if so, whether any such waiver would apply to your facility, contact your State Survey Agency
(SA) or the Medicare contractor to which you submit claims. In some circumstances, providers may be
required to submit documentation of need for a grant of waiver of certain requirements. In that event the SA
or your servicing Medicare contractor will advise you of specific requirements. All providers impacted by an
emergency or disaster should activate their disaster plans, especially those providers furnishing emergency
treatment subject to the Emergency Medical Treatment and Labor Act (EMTALA).
Providers should assume that normal Medicare facility rules remain in effect unless official notice is made that
waivers of such rules have been granted.
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C – General Payment Policies
Question Question and Answer
Number
C-1 Question: Will Medicare fee-for-service pay when beneficiaries wish to get services in a State other than
their home State?
Answer: Yes. Fee-for-service (FFS) Medicare beneficiaries, that is beneficiaries who are enrolled in Original
Medicare, may obtain health care services anywhere in the country. This is normal policy. The provider of
services will bill the Medicare contractor with whom they are enrolled and with whom they normally conduct
Medicare business.
Non-FFS beneficiaries, that is beneficiaries enrolled in other types of Medicare plans (Medicare Advantage
(MA), PACE, HCPPs enrollees, etc.), may be limited as to where they may obtain services but generally can
obtain urgently needed or emergency health care services anywhere.
C-2 Question: Are contractors allowed to extend the due date for cost reports, to allow the providers additional
time to submit them without having payments interrupted?
Answer: Yes, 42 CFR § 413.24(f)(2)(ii) allows this flexibility, “if a provider’s operations are significantly
adversely affected due to extraordinary circumstances over which the provider has no control, such as flood
or fire.”
C-3 Question: In declared disasters, can CMS make payment for services that are provided by healthcare
professionals who, in normal circumstances, would not be permitted by Medicare to bill for their services to
beneficiaries (e.g., RNs providing care typically provided by physicians or residents/medical students
providing services without the required level of physician supervision)?
Answer: No. There is no authority under Medicare Part B that permits a Medicare contractor to depart from
the statutory provisions that specify to whom Medicare payment is made. Medicare payment cannot be made
under the physician fee schedule (PFS) directly to an RN or any other individual without a separately specified
benefit under Medicare law. The only way that these individuals can receive Medicare Part B payment for
their services to Medicare patients is indirectly under the “incident to” provision. The “incident to” provision
requires, among other things, that PFS payment is made to the employer of those who furnish services
incident to a physician’s (or to certain types of non-physician practitioner’s) professional service and that the
services be furnished under direct supervision by a physician (or certain types of non-physician practitioners).
Hence, those who provide “incident to” services must be employed, leased, or contracted with the physician
or non-physician practitioner, or the entity that bills for their services.
C-4 Question: What types of healthcare facilities qualify for reimbursement?
Answer: A hospital, critical access hospital, skilled nursing facility, rural emergency hospital, comprehensive
outpatient rehabilitation facility, home health agency, or hospice program, as defined in the Act, may be paid
under Medicare as “providers”. A physician or other practitioner, suppliers of equipment and healthcare
supplies, and other types of mostly outpatient facilities, as defined in the Act, may be paid as
“suppliers”. Information on the Medicare certification requirements for various types of providers and
institutional suppliers may be found on the Survey and Certification portion of CMS’
website: https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Provider-Survey-
and-Certification-Frequently-Asked-Questions.pdf
C-5 Question: Can LTC facilities be reimbursed separately for costs incurred in evacuation?
Answer: No statutory authority permits Medicare to pay for evacuation costs. Moreover, even in the
circumstance where the HHS Secretary invokes the waivers authorized by § 1135 of the Social Security Act,
evacuation costs would not be covered under Medicare by such waivers. However, depending on particular
circumstances, an ambulance transport to the nearest appropriate facility equipped to treat the beneficiary
may be covered by Medicare Part B if transport of the beneficiary by ambulance was medically necessary and
all other normal Medicare coverage requirements were met (i.e., the vehicle must meet certain requirements,
the crew must be certified as required, the transport must be from an eligible origin to an eligible destination,
certain billing and reporting requirements must be met, and Medicare Part A payment is not made directly or
indirectly for the services). The Medicare Administrative Contractor (MAC) would evaluate such transports on
a case-by-case basis.
C-6 Question: If a provider affected by a disaster has facility damage or destruction which results in the loss of
documentation used to support payment, what flexibility is available?
Answer: Instructions for how to handle situations where documentation to support payment has been lost or
destroyed can be found in CMS’ Program Integrity Internet Only Manual in Publication 100-08, Chapter 3, §
3.8 entitled “Administrative Relief from MR During a Disaster” at the following
link: http://www.cms.gov/manuals/downloads/pim83c03.pdf.
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D – General Billing Procedures
Question Question and Answer
Number
D-1 Question: Regarding the use of the disaster-related condition code “DR”, should this code be used for all
billing situations relating to a declared emergency/disaster (i.e., SNF, ESRD, or Hospitals)?
Answer: Yes, the “DR” condition code should be used by institutional providers (but not by non-institutional
providers such as physicians and other suppliers) in all billing situations related to a declared
emergency/disaster. The “DR” condition code is intended for use by providers (but not by physicians and
other suppliers) in billing situations related to a declared emergency/disaster. However, use of the DR
condition code, which previously was left to the provider’s or supplier’s discretion, is now to be used only in
certain circumstances. Effective August 31, 2009, use of the DR condition code is mandatory for any claim
for which Medicare payment is conditioned on the presence of a “formal waiver” (as defined in the CMS
Internet Only Manual, Publication 100-04, Chapter 38, § 10). Also, the DR condition code may be required in
certain circumstances relating to a particular disaster or emergency to facilitate efficient processing of
claims. Medicare claims processing contractors will advise providers when and under what circumstance such
ad hoc use of the DR condition code will be required. (Note: Non-institutional providers do not use the DR
condition code. Instead, non-institutional providers must use the CR modifier for applicable HCPCS codes on
any claim for which Medicare Part B payment is conditioned on the presence of a “formal waiver”. The CR
modifier also may be required for any HCPCS code for which, at the Medicare claims processing contractor’s
discretion or as directed by CMS in a particular disaster or emergency, the use of the CR modifier is needed to
efficiently and effectively process claims or to otherwise administer the Medicare fee-for-service program.)
D-2 Question: Please provide direction regarding the use of the CR/DR modifier/condition code on claims for
services furnished to patients that were moved to other areas, including other States outside the emergency
area. Does a provider still use the CR/DR modifier/condition code when the provider is in a State other than
the State where the emergency has been declared?
Answer: Agency policy concerning the use of the DR condition code and the CR modifier is established in
CMS Internet Only Manual (IOM) Publication 100-04, Chapter 38, § 10. This Change Request provides that
the DR condition code and the CR modifier are required in any one of three circumstances as follows: 1) a §
1135 waiver granted to a provider or supplier necessitates the use of the condition code or modifier, 2) CMS
mandates their use, or 3) a claims administration contractor mandates their use. See Change Request 6451
for a more precise statement of the policy. When the President declares an emergency and the Secretary of
the Department of Health and Human Services has also declared a public health emergency, CMS advises its
contractors that use of the DR condition code or the CR modifier is required on a claim for an item or service
furnished under a “formal waiver,” i.e., the first of the three possibilities discussed in Change Request 6451,
and will also specify the emergency area and the beginning effective date. If CMS were to mandate the use
of the condition code or modifier in other circumstances, i.e., the second of the three possibilities discussed in
Change Request 6451, that decision would also be communicated to our contractors. Finally, under Change
Request 6451, claims administration contractors are authorized – but not required – to mandate or authorize
the use of the DR condition code or the CR modifier on claims related to a particular emergency, including
claims from providers and suppliers furnishing items and services in States other than the State in which the
emergency exists when the effects of the emergency affect the delivery of such items and services in other
States. This is the third of the three possibilities discussed in Change Request 6451. Note, however, that the
requirement or authorization to the use the DR condition code or the CR modifier on a claim does not, itself,
constitute a waiver of a Medicare requirement, but rather reflects that a waiver or other special condition may
apply to the furnishing of an item or service in a Federally-declared emergency situation. In each case where
the DR condition code or the CR modifier is required, our contractors will notify providers and suppliers of the
particulars regarding such use.
D-3 Question: How does CMS want contractors to handle 5601 edits (overlaps) when one of the facilities is an
emergency/disaster-impacted provider and the contractor is unable to contact it or obtain documentation?
Contractors often request admit and discharge summaries from providers in order to resolve overlapping
claims issues. What should contractors do when one of the providers is in the emergency/disaster-impacted
area and the contractor is unable to contact it and obtain documentation?
Answer: When two claims are overlapping and it is necessary to view the admission and discharge
summaries to ascertain where the patient was on a given day, the contractor should pay the claim for the
facility that is able to provide the documentation to support the days on their claim. Upon contacting the
affected provider, contractors may make any necessary adjustments to the claims.
D-4 Question: How should the CR modifier and the DR condition code be used for emergency related claims?
Answer: The CR modifier and the DR condition code are still authorized for emergency-related claims. But
see CMS Internet Only Manual (IOM) Publication 100-04, Chapter 38, § 10 for updated procedures related to
the use of the CR modifier and the DR condition code, and Section 38.10 of the Claims processing manual.
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Question Question and Answer
Number
D-5 Question: Are there exceptions to the time limits for filing claims?
Answer: The law requires that all claims must be filed no later than 1 calendar year after the date of
service. However, there are four regulatory exceptions to the time limits for filing claims (see 42 C.F.R. §
424.44(b)(1) through (4) for details). Section 70.7 et.al. of Publication 100-04, Chapter 1 (General Billing
Requirements) of the Internet Only Manual provides instructions on the process for submitting a request to
the Medicare contractor for a regulatory exception to the timely filing requirements. We do not believe that
providers or suppliers affected by an emergency/disaster would be adversely affected by the timely filing
requirement given that the timely filing window is within 1 calendar year after the date of service. However,
we may consider requests for modifications to the deadline under section 1135 authority on a case-by-case
basis.
D-6 Question: What does CMS recommend for filing claims during a declared emergency?
Answer: If an emergency were to cause difficulties in filing claims electronically, providers may request an
exception due to unusual circumstances as defined in Section 90-3 et.al. of Publication 100-04, Chapter 24
(General EDI and EDI Support Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare
Claims). or
D-7 Question: What should providers do when treating a Medicare beneficiary who cannot provide his or her
Medicare health insurance identification number at the time services are rendered?
Answer: Medicare beneficiaries should not be denied emergency healthcare services.
During a situation where the health care needs are not an emergency, the provider should instruct the
beneficiary to call the Social Security Administration at 1-800-772-1213 to obtain a new card or to order one
on-line at: https://www.hhs.gov/answers/medicare-and-medicaid/how-do-i-replace-my-medicare-
card/index.html
Providers should hold their claims until the beneficiary receives the new card and provides them with their
Medicare number. Claims cannot be processed without the Medicare Number (or health insurance claim
number). The Medicare regulation at 42 CFR § 424.44 defines the timely filing period for Medicare fee-for-
service claims. In this circumstance, claims must be filed within 1 calendar year after the date of
service. The timely filing period should allow adequate time for the provider to receive the health insurance
number and file the claim.
In those situations where the beneficiary requires emergency healthcare services in a natural or manmade
disaster, the provider should attempt to obtain the Medicare number from the beneficiary, beneficiary’s family
members, or other providers such as transferring facilities, if possible. Providers can also share patient
information to the extent necessary to seek payment for these health care services. If the provider cannot
obtain the Medicare number through these other individuals, providers should contact the local Medicare
contractor to request the Medicare number. Individual practitioners, such as a sole proprietorship, should be
prepared to furnish the following information regarding their enrollment in the Medicare program: the
provider’s Social Security Number, date of birth and PTAN. Organizational providers should be prepared to
furnish the following information about their enrollment in the Medicare program: the name of the authorized
or delegated official on file for the provider.
D-8 Question: In the event of a declared emergency or disaster that results the provider’s loss of the means to
submit claims electronically may the provider submit paper claims?
Answer: If such a disruption is expected to last more than 2 business days, affected providers are
automatically waived from the electronic submission requirement for the duration of the disruption. If
duration is expected to be 2 business days or less, a provider should simply hold claims for submission when
power and/or communication are restored. A provider is to self-assess when this circumstance applies, rather
than apply for contractor or CMS waiver approval. A provider may submit claims to Medicare on paper or via
other non-electronic means when this circumstance applies. A provider is not expected to pre-notify its
Medicare claims administration contractor that this circumstance applies as a condition of submission of non-
electronic claims.
E – Physician Services
Question Question and Answer
Number
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E-1 Question: If a physician leaves his/her location to provide services to beneficiaries in a jurisdiction/locality
outside of his/her usual jurisdiction/locality, must the physician bill based upon the new location or may
he/she bill based upon his/her usual jurisdiction/locality?
Answer: Under Section 1848 of the Social Security Act. Physicians must bill and be paid for the service based
upon the actual location/locality in which the service is rendered.
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Question Question and Answer
Number
E-2 Question: Will the 60-day limit for Fee-For-Time Compensation Arrangements (formerly referred to as
Locum Tenens Arrangements) and Reciprocal Billing Arrangements be extended for those affected by the
disaster? Some physicians in nearby States are going to the affected disaster areas to help out. In their
absence, physicians (i.e., temporary or substitute physicians) are substituting for the physicians leaving their
medical practices to work in the disaster areas.
Answer: Medicare policy allows physicians to cover absences of longer than 60 days by hiring multiple
substitute physicians. For example, if a physician needs to be absent from their medical practice for 120 days,
the absent physician may hire one substitute physician to work the first 60-day period and a different
substitute physician to work the second 60-day period. As an alternative to hiring more than one substitute
physician, an absent physician could return to work in their practice for a short period of time to reset the 60-
day clock. We note that Medicare policy (for Fee-For-Time Compensation Arrangements and Reciprocal Billing
Arrangements) does not allow absent physicians to bill for substitute physicians for an indefinite period of
absence, nor does Medicare policy allow physicians and other entities to bill for substitute personnel to fill
staffing voids.
E-3 Question: If a practitioner is temporarily working out of another doctor’s office (within the same State) due
to damage from the emergency, would they need to file a Change of Address for this temporary site?
Answer: All physicians and non-physician practitioners must report a change in practice location within 30
days of the change. See § 424.516(d). Physicians and non-physician practitioners can submit the application
via the Provider Enrollment Chain and Ownership System (PECOS) or the CMS 855 paper enrollment
application.
E-4 Question: Will Health Professional Shortage Areas (HPSAs) be extended/expanded in an emergency or
disaster?
Answer: There are no plans at this time to implement an accelerated HPSA process for areas affected by an
emergency or disaster.
E-5 Question: During an emergency/disaster, is it possible for civilian physicians to bill Medicare and Medicaid
for care provided to patients in military facilities?
Answer: Medicare is precluded from making payment for services or items that are paid for directly or
indirectly by another government entity. However, current Medicare Part B physician payment policy does
allow a physician who is individually enrolled in Medicare, and not an employee or contractor of the federal
facility, to separately bill Medicare for services provided to a Medicare beneficiary, using the appropriate place
of service code. Place of service (POS) code 26 is to be used for services provided in Military Treatment
Facilities, which are medical facilities operated by one or more of the Uniformed Services. Military Treatment
Facility also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as
Uniformed Service Treatment Facilities (USTF). Physician services provided in these locations are paid at the
physician facility rate. A complete listing of available place of service codes can be found in Chapter 26 of the
Medicare Claims Processing Manual.
F – Ambulance Services
Question Question and Answer
Number
F-1 Question: If the ambulance crew provides treatment but does not transport anyone, can the company bill
Medicare for the services provided?
Answer: No. Medicare law prohibits payment unless the transport of a Medicare beneficiary has taken place.
F-2 Question: Will Medicare pay for ambulance services for emergency evacuation situations?
Answer: MACs may make payment for ambulance transports for evacuating patients from locations affected
by an emergency/disaster. The regulatory requirements must be met in order for such ambulance transports
to be covered (i.e., the vehicle must meet certain requirements, the crew must be certified, ambulance
services must be medically necessary, the transport must be from an eligible origin and to an eligible
destination, certain billing and reporting requirements must be met, and Medicare Part A payment is not
made directly or indirectly for the services).
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Question Question and Answer
Number
F-3 Question: How will ambulance services be paid when patients are moved from hospital to hospital or other
approved locations?
Answer: Charges for ambulance transportation will be paid according to the usual payment guidelines.
Ambulance transportation charges for patients who were evacuated from and returned to originating hospitals
should be included on the inpatient claims submitted by the originating hospitals. Payment will be included in
the diagnostic related group (DRG) payment amounts made to hospitals paid under the prospective payment
system. Outpatient claims may be submitted as separately billable claims for ambulance charges incurred by
those patients who were transported from the originating hospitals and subsequently discharged by receiving
hospitals.
F-4 Question: Will Medicare cover ambulance transportation (under Part B) for a beneficiary who has been
evacuated from a skilled nursing facility due to an emergency/disaster, and who wishes to return to a nursing
facility closer to family members or home after the emergency/disaster is over?
Answer: Part B of the Medicare program covers only local ambulance transportation to and from the nearest
appropriate SNF equipped to treat the beneficiary, as long as the beneficiary is not a SNF resident in a
covered Part A stay whose transport would be subject to consolidated billing rules. If there are exceptional
circumstances that require transport outside the locality, Medicare can pay for this transport, but only if the
destination is still the nearest SNF with appropriate facilities. In any case, the ambulance transport must be
medically necessary.
F-5 Question: Do the condition code “DR” (disaster related) and modifier “CR” (catastrophic/disaster related)
apply to hospital-based ambulance providers?
Answer: The “DR” condition code and the “CR” modifier both apply to ambulance claims submitted by
institutional providers to Medicare FIs or MACs. However, only the “CR” modifier, but not the “DR” condition
code, applies to suppliers submitting claims to Medicare Carriers or MACs. Neither carriers nor the Part B side
of MACs use the “DR” condition code.
F-6 Question: For ambulance claims submitted by institutional providers, does it matter which modifier (the
“CR” modifier or the “DR” condition code) is used for an institutional claim?
Answer: An institutional provider would use the “CR” modifier to designate any service line item on the
claim that is disaster related. If all of the services on the claim are disaster related, the institutional provider
should use the “DR” condition code to indicate that the entire claim is disaster related.
F-7 Question: For ambulance claims submitted by institutional providers, where would we use the “CR” modifier
on institutional claim submittals?
Answer: On the ANSI X12 837 Institutional claim format, this information would go in loop 2400 SV202-3 or
SV202-4. On a paper claim, it would be entered in block 44 on the CMS UB-04 form.
F-8 Question: For ambulance claims submitted by institutional providers, where would we use the “DR” (disaster
related) condition code on institutional claim submittals?
Answer: On the ANSI X12 837 Institutional claim format, this information would go in loop 2300 HI01-2. On
a paper claim, it would be entered in blocks 24 -30 on the CMS UB-04 form.
F-9 Question: On claims for ambulance services, would I include the origin/destination modifiers?
Answer: You should include an origin/destination modifier for all ambulance claims submitted for separate
payment and that are not, under Medicare rules, included in the Medicare payment for an inpatient
institutional service.
F-10 Question: If a beneficiary, living at home and using a stationary oxygen unit, has to be transported to
another location by ambulance (because other means of transportation are contraindicated), can Medicare
pay for any portable oxygen necessary to transport the beneficiary?
Answer: Medicare’s payment to ambulance providers and suppliers includes payment for all necessary
supplies, including oxygen. Thus, if the transport is a Medicare-covered service (e.g., the beneficiary must be
transported by ambulance because other means of transportation are contraindicated), then no separate
payment for furnishing oxygen would be available. However, if the transport does not qualify as a Medicare-
covered service, then payment under Part B may be made to a DME supplier for furnishing portable oxygen
when supplemental oxygen is needed for the beneficiary during the transport.
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F-11 Question: In emergency/disaster situations how does CMS define an “approved destination” for ambulance
transports, and would it include alternate care centers, field hospitals and other facilities set up to provide
patient care in response to the emergency/disaster?
Answer: CMS defines “approved destination” in the Code of Federal Regulations (CFR), 42 CFR § 410.40(e),
Origin and Destination requirements. Medicare can only pay for ambulance transportation when it meets the
Origin and Destination Requirements and all other coverage requirements in Medicare regulations and
manuals. These requirements specify that an appropriate destination is one of the following:
∙ Hospital;
∙ Critical Access Hospital (CAH);
. Rural Emergency Hospital (REH);
∙ Skilled Nursing Facility (SNF);
∙ Beneficiary’s home;
∙ Dialysis facility for ESRD patient who requires dialysis.
Beneficiaries residing in a SNF who are receiving Part B benefits only are eligible for ambulance transport to
one additional “approved destination”: From a SNF to the nearest supplier of medically necessary services
not available at the SNF where the beneficiary is a resident. For SNF residents receiving Medicare Part A
benefits, this type of ambulance service is subject to SNF consolidated billing.
A physician’s office is not a covered destination. However, under certain circumstances an ambulance
transport may temporarily stop at a physician’s office without affecting the coverage status of the transport.
We do not expect an emergency/disaster to affect the availability of hospital or other facility services;
however, should a facility which would normally be the nearest appropriate facility be unavailable during an
emergency/disaster, Medicare may pay for transportation to another facility so long as that facility meets all
Medicare requirements and is still the nearest facility that is available and equipped to provide the needed
care for the illness or injury involved.
42 CFR 410.40 allows Medicare to pay for an ambulance transport (provided that transportation by any other
means is contraindicated by the patient’s condition and all other Medicare requirements are met) from any
point of origin to the nearest hospital, CAH, REH, or SNF that is capable of furnishing the required level and
type of care for the beneficiary’s illness or injury. The hospital or CAH must have available the type of
physician or physician specialist needed to treat the beneficiary’s condition.
The waiver authority under § 1135 does not authorize a waiver of the ambulance payment and coverage
requirements, such as the approved destination requirements described above. However, Medicare payment
for an ambulance transport to an alternative care site may be available if the alternative care site is
determined to be part of an institutional provider (hospital, CAH, REH, or SNF) that is an approved destination
for an ambulance transport under 42 CFR § 410.40 (whether under a § 1135 waiver or existing rules). If the
alternative care site is granted approval by the State Agency to be part of an institutional provider (hospital,
CAH, REH, or SNF) that is an approved destination under 42 CFR § 410.40 for an ambulance transport,
Medicare will pay for the transport on the same basis as it would to any other approved destination in the
absence an 1135 waiver.
F-12 Question: If Emergency Medical Services (EMS) providers render care and advice at the site, and release or
redirect patients to primary care and not the Emergency Department, will this care be reimbursed as an
Emergency Visit?
Answer: With respect to Medicare FFS, there is no statutory benefit category that allows Medicare to pay for
the services of an emergency medical technician (EMT) or paramedic in the absence of a medically necessary
ambulance transport. The Medicare statute does allow payment to ambulance providers and suppliers.
However, the Medicare ambulance benefit covers only: a medically necessary ambulance transport of a
Medicare beneficiary to the nearest appropriate facility (e.g., a hospital or critical access hospital or rural
emergency hospital) equipped to treat the beneficiary and other means of transportation are contraindicated.
Medicare Part B payment to the ambulance provider or supplier under the ambulance fee schedule (AFS)
covers both the ambulance transport including a separate payment for mileage and all covered supplies and
services associated with such transport as may be medically necessary for the beneficiary. The statute does
not permit payment to an ambulance provider (e.g., hospital owned) or supplier without transport even if a
waiver is in effect under section 1135 of the Social Security Act. Therefore, no separate Medicare FFS
payment is available for services provided by an EMT or paramedic.
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F-13 Question: If a Medicare beneficiary is transported by ambulance to a local skilled nursing facility (SNF)
because the ambulance was unable to transport the beneficiary to the hospital located in another community
for factors such as weather, would Medicare payment be available under either of the following two scenarios?
1. The ambulance service would use space in the SNF that was not used by patients and would provide
the care for the patient under the direction of the ambulance EMS medical director.
2. The staff from the SNF would help provide care for the patients, freeing the ambulance service staff
to take other calls.
Answer: These scenarios implicate both payment policy and conditions of participation and the permissibility
of either scenario may depend on whether a waiver under § 1135 of the Social Security Act has been granted
to the SNF in question. First, in the absence of an 1135 waiver, if the patient needs a hospital level of care
and not a SNF level of care, the SNF cannot be considered a hospital alternative care site. Therefore, the
ambulance transport of the patient to the SNF would not be payable under Medicare because the SNF would
not be the nearest appropriate facility that is capable of furnishing the required level and type of care for the
beneficiary’s illness or injury (see 42 CFR § 410.40(f) for destination requirements under the AFS. In
addition, because the SNF cannot be considered a hospital alternative care site for furnishing a hospital level
of care, no Medicare payment would be available for any services furnished to the patient while a resident of
the SNF.
Even if 1135 waivers were generally available for a particular emergency, because SNFs are not equipped to
provide a hospital level of care, and because neither of the described scenarios entail a hospital working with
a SNF to create an alternate hospital care site at the SNF, with the hospital providing additional staffing, CMS
would likely have strong reservations about approving such a waiver request, regardless of whether or not
the ambulance service would be providing personnel to monitor the patient(s) at the SNF. However, CMS
would review the particular circumstances of the actual situation to make a determination under an 1135
waiver as to what practices would be permitted, along with whether Medicare could pay for any covered
services, and under which benefit the services would be paid.
G – Laboratory & Other Diagnostic Services
Question Question and Answer
Number
G-1 Question: In situations where laboratory specimens are destroyed or compromised by a disruptive event,
how will laboratories be paid?
Answer: Contractors may consider payment for another drawing fee, specimen transport, or test if the
results have not been communicated to the patient’s physician.
G-2 Question: Will Medicare pay for diagnostic tests for infectious diseases (e.g., nasal swabs) for beneficiaries?
Answer: Under Part B, Medicare will cover diagnostic tests as set forth in 42 CFR § 410.32 and other existing
policies. Note, however, that the Social Security Act contains exclusions that bar payment if an item or
service was provided free of charge and in other circumstances as specified in 42 CFR Part 411.
G-3 Question: Will Medicare reimburse for rapid flu tests?
Answer: Rapid Flu tests may be considered a Medicare benefit under § 1861(s)(3) of the Social Security Act
as a diagnostic laboratory test. All services, including rapid flu tests, furnished under the Medicare program
must be medically reasonable and necessary and appropriate for diagnosis and/or treatment of an illness or
injury.
H – Drugs & Vaccines Under Part B
Question Question and Answer
Number
H-1 Question: Will Medicare help pay for an influenza vaccine only if it has been approved by the FDA?
Answer: Yes, Medicare will cover a vaccine only if the FDA has approved it or authorized its distribution,
including approvals/authorizations under the FDA’s emergency use authority under § 564 of the Federal Food,
Drug, and Cosmetic Act.
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H-2 Question: Will Medicare pay for a physician’s administration of an influenza vaccine to a beneficiary?
Answer: Yes, Medicare pays for the administration of the vaccine when it is administered by a qualified
Medicare provider or supplier who meets the applicable requirements for billing for the standard influenza
virus vaccine and its administration.
H-3 Question: Will Medicare Part B pay for vaccinations of Medicare beneficiaries?
Answer: Medicare Part B pays for preventive Hepatitis B vaccines and their administration for high-and
intermediate-risk beneficiaries, and also for influenza, pneumococcal and COVID-19 vaccines and their
administration for all Medicare beneficiaries. Medicare Part B will also pay for medically reasonable and
necessary vaccinations of beneficiaries against a microbial agent or its derivatives (e.g., tetanus toxin,
Hepatitis A), or any other that vaccines that are reasonable and necessary for the diagnosis or treatment of
illness or injury (e.g. rabies, mpox), following likely exposure in accordance with normal Medicare coverage
rules.
H-4 Question: What can Medicare beneficiaries, who generally receive their Part B drugs at the doctor’s office,
do when that office is inaccessible?
Answer: If possible, patients should contact their original physician’s office to determine if there is an
alternate location where they can receive services. If this is not possible, then patients may find another
physician. That new physician can provide the necessary Part B drugs and Medicare will pay for them since
beneficiaries in original, i.e., fee-for service, Medicare can receive health care services anywhere in the
country. (Note: Medicare Advantage (MA) enrollees also can get urgently needed or emergency health care
services anywhere.)
H-5 Question: If a State distributes CDC's Strategic National Stockpile (SNS) drugs to hospitals, what are the
Medicare billing rules? How should hospitals handle billing for services that involve the use of SNS provided
drugs?
Answer: For services rendered to Medicare fee-for-service (FFS) beneficiaries, standard Medicare FFS billing
rules apply. This would include following existing policy on no cost items, such as SNS drugs located in the
CMS Internet Only Manual Pub. 100-04, Chapter 32, Section 67 which states that provider may not seek
reimbursement for no cost items as noted in Section 1862(a)(2) of the Social Security Act.
H-6 Question: Will Medicare Part B cover a 90-day supply of drugs for an individual beneficiary in the event that
a pandemic occurs, when such drugs are needed to address a chronic condition?
Answer: With respect to drugs covered under Part B, with the exception of immunosuppressive drugs --
which are generally limited to a 30-day supply – but including drugs that need to be administered through
DME, contractors have discretion to pay for a greater-than-30-day supply of drugs. When considering
whether to pay for a greater-than-30-day-supply of drugs, contractors will take into account the nature of the
particular drug, the patient’s diagnosis, the extent and likely duration of disruptions to the drug supply chain
during an emergency, and other relevant factors that would be applicable when making a determination as to
whether, on the date of service, an extended supply of the drug was reasonable and necessary.
With respect to immunosuppressive drugs, although Medicare would customarily not pay for more than a 30-
day supply (because dosage frequently diminishes over a period of time and because it is not uncommon for
the physician to change the prescription from one drug to another), in the event of an emergency, contractors
may consider allowing payment for a medically necessary, greater-than-30-day supply of Medicare-covered,
immunosuppressive drugs on a case-by-case basis.
H-7 Question: A Medicare beneficiary’s supply of a Part B covered drug was affected by the emergency such that
the remainder of the prescribed amount of the drug became unusable or lost and must be replaced. Will
Medicare pay for a replacement prescription within the timeframe covered by the original prescription?
Answer: Contractors may allow payment for replacement prescription fills (for a quantity up to the amount
originally dispensed) when reasonable and necessary in circumstances where the dispensed medication is lost
or otherwise rendered unusable by damage due to the emergency. Non-institutional providers must use the
CR modifier in billing situations related to a declared emergency/disaster. In addition, non-institutional
providers should keep documentation that indicates whether the drug was lost, destroyed, irreparably
damaged or otherwise rendered unusable as a result of the disaster.
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H-8 Question: Can a Medicare beneficiary receive more than a 30-day supply of Medicare Part B covered drugs
during an emergency?
Answer: In most situations where there are specific limits on coverage of additional quantities or time limited
coverage periods that are 30 days or less, Medicare Part B does not pay for additional quantities. For
example, oral anti-emetic drugs are covered only when they are used immediately before, at, or within 48
hours after administration of an anticancer chemotherapeutic agent. For immunosuppressive drugs, claims
processing contractors will generally not consider a supply of immunosuppressive drugs in excess of 30 days
to be reasonable and necessary and will deny payment. However, contractors have the authority to make
exceptions for the 30-day limit on immunosuppressive drug under special circumstances; information on such
exceptions would be made available by the Medicare Administrative Contractor that processes a provider or
supplier’s immunosuppressive drug claims.
Source: https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c17.pdf, (Exception for “special circumstances” is in section
80.3)
I – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Question Question and Answer
Number
I-1 Question: If a beneficiary’s durable medical equipment, prosthetic, orthotic, or supply (DMEPOS) is lost or
irreparably damaged due to a circumstance related to an emergency, can the beneficiary obtain a
replacement item and if so, how would the supplier bill for such item?
Answer: Yes, a beneficiary is generally able to receive replacement of DMEPOS when it is lost, damaged,
destroyed, or otherwise rendered unusable due to a circumstance related to an emergency.
Policy
See the Medicare Claims Processing Manual, Chapter 20, Section 50, regarding Medicare’s customary
payment policy for replacement of DMEPOS. This policy remains in effect even when an emergency or major
disaster is declared by the President of the United States. The following explains the existing policy:
Except as noted below, Medicare pays for the replacement of equipment/items which the beneficiary owns,
oxygen equipment, or capped rental items that were lost, destroyed, irreparably damaged, or otherwise
rendered unusable.
Medicare does not pay for the replacement of equipment/items that require frequent and substantial
servicing as defined in 42 CFR 414.222. Payment for the replacement of the oxygen equipment and capped
rental equipment other than complex rehabilitative power wheelchairs is made by starting a new 36-month
rental period for oxygen equipment or a new 13-month rental period for capped rental equipment. Payment
for replacement of complex rehabilitative power wheelchairs (Healthcare Common Procedure Coding System
(HCPCS) codes K0835 thru K0864) can be made on a lump sum purchase or rental basis.
In all cases for which Medicare payment of replaced equipment/items is available, the replacement must be
furnished by a Medicare-enrolled supplier. New face-to-face and physician’s order are still in effect, unless
specified otherwise by the Centers for Medicare & Medicaid Services (CMS).
Billing
The “CR” modifier (catastrophe/disaster related) should be included on claims when a formal waiver has
been issued as described above.
The “RA” modifier (replacement of durable medical equipment (DME)) is always required on a claim line for a
replacement item. If the beneficiary is displaced from a federally declared emergency or major disaster area,
the beneficiary may obtain the replacement item from a Medicare-enrolled supplier located outside such
area. If the supplier is aware that the item is a replacement, the supplier should annotate the claim line with
the “RA” modifier.
The “99” modifier (modifier overflow) should be used if the claim line requires more than four modifiers to
indicate to the Medicare Administrative Contractor (MAC) that one or more additional modifiers are
applicable.
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I-2 Question: If a beneficiary living at home and using a stationary oxygen unit has to be transported to
another location, can Medicare pay for any portable oxygen necessary to transport the beneficiary?
Answer: Yes. Medically necessary oxygen in connection with and as part of the ambulance service would be
included in Medicare’s AFS payment to an ambulance provider or supplier when a beneficiary is transported
by ambulance and such transport is a Medicare-covered service. In addition, separate payment under Part B
can be made to a DME supplier for portable oxygen when medically necessary to transport the beneficiary if
the transport itself is not covered by Medicare.
I-3 Question: Will Medicare cover and pay for a surgical mask to prevent the spread of infectious diseases, if
prescribed by a physician?
Answer: No. There is no Medicare benefit category that would allow for separate coverage of a surgical
mask.
I-4 Question: Will CMS cover the cost of a generator for medical needs?
Answer: Although a generator may be used to power DME, it is not, nor can it be considered to be, medical
equipment. By law, Medicare does not have the authority to pay for generators.
I-5 Question: A supplier has been dispensing portable oxygen tanks to beneficiaries every day because power
is out in their area and their oxygen concentrators do not function without power. Can CMS provide
reimbursement in addition to the fee schedule amount that the supplier is already receiving for that patient?
That is, due to the above-normal amount being dispensed, can payment be higher than the usual monthly
oxygen payments? If so, would there be any particular billing requirements other than the "CR" modifier?
Answer: No. If a supplier chooses to provide portable oxygen equipment in lieu of stationary equipment
during this time, the supplier will not receive an additional Medicare payment. If a beneficiary’s concentrator
does not work due to a power outage, the supplier may meet the beneficiary’s stationary oxygen needs by
furnishing gaseous or liquid stationary equipment until the power is back on in the beneficiary’s home. The
supplier may also choose to pick up the concentrator while the beneficiary is using other stationary oxygen
modalities.
Medicare payment for stationary oxygen equipment, stationary oxygen contents, and portable oxygen
contents are included in the supplier’s monthly fee schedule payment amount. A supplier may receive an
“add on” amount as payment for portable oxygen equipment in certain situations if a beneficiary receives
portable oxygen after a finding of medical need.
I-6 Question: Can the face-to-face requirement for certain DMEPOS be waived in an emergency?
Answer: The face-to-face requirement may only be waived if the Secretary determines it is necessary in
the emergency and issues a waiver under section 1135. If such conditions apply, CMS will notify the public
on its Emergency Response and Recovery website. Absent a formal waiver indicated above, the face-to-face
requirement remains in effect.
I-7 Question: How can people with Medicare who have been displaced without access to their usual suppliers
get access to DMEPOS, such as wheelchairs and therapeutic shoes?
Answer: Beneficiaries who have access to a telephone may contact 1-800-MEDICARE for information
regarding suppliers servicing their current location. Alternatively, if beneficiaries have access to the Internet,
they go to the following medicare.gov website to obtain a directory listing suppliers by geography, proximity
and name: http://www.medicare.gov/supplier.
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I-8 Question: Could CMS summarize Medicare’s payment rules regarding payment for oxygen services in an
emergency, especially with regard to changes in delivery modalities (portable versus stationary) made
necessary by the emergency?
Answer: The Medicare monthly payment amount for oxygen and oxygen equipment includes payment for all
of the different oxygen modalities (concentrator, liquid, gaseous) and also includes payment for portable
oxygen contents. If suppliers have to switch patients to a different modality (i.e., from concentrator to
gaseous or liquid stationary), for example, because of a power outage, the Medicare payment already factors
those costs into the monthly payments. Therefore, no additional payment for switching to a different
modality can be made in these situations as the Medicare payment includes payment for all modalities.
The monthly portable equipment add-on payment includes an additional payment (added on to the monthly
payment for oxygen and oxygen equipment) when portable equipment is used and medically necessary. This
is only an add-on payment to the monthly payment amount for oxygen and oxygen equipment and should
not be confused with a monthly payment for furnishing portable oxygen equipment and oxygen contents.
The Medicare monthly payment amounts for the gaseous and liquid portable equipment add-ons differ, so
additional payment would be available if suppliers switch patients from gaseous to liquid portable equipment.
Again, the Medicare monthly payment for oxygen and oxygen equipment includes payment for all modalities
of stationary oxygen and payment for any necessary oxygen contents, both stationary and portable oxygen
contents.
The portable equipment add-on payment can be made in cases where the patient was not already using
portable oxygen equipment and needs to be furnished with portable oxygen equipment, for example, during
a federally-declared emergency or major disaster. However, if the patient was already receiving gaseous
portable oxygen equipment, additional payments beyond what the supplier is already receiving for furnishing
gaseous portable oxygen equipment on a monthly basis cannot be made because this amount includes the
monthly payment amount and the add-on payment. The same would hold true if the patient was already
receiving liquid portable oxygen equipment, in that there would be no additional payments beyond what the
supplier is already receiving for furnishing liquid oxygen on a monthly basis.
Finally, if oxygen equipment is lost, for example, as a result of a federally-declared emergency or major
disaster, the supplier can follow the normal process for submitting a claim for replacement of the lost
equipment in disaster situations. Medicare starts the 36-month payment period over in situations where lost
oxygen equipment must be replaced and proper documentation describing the need for replacement and the
required medical necessity documentation is furnished. The DME MACs will process the claims for
replacement of lost oxygen equipment using the process established for processing disaster claims.
I-9 Question: Due to limited utilities (phone, power and internet), a beneficiary seeks to have a secondary
provider to support his/her respiratory needs during the state of emergency. Can the secondary provider bill
for respiratory services rendered to a patient residing in the federally-declared emergency or major disaster
area?
Answer: The alternate supplier of oxygen and oxygen equipment needs to seek payment from the supplier
that received the Medicare monthly payment amount for the remainder of the paid month during which the
beneficiary relocated or needed to obtain services from an alternate supplier. The Medicare fee-for-service
program does not authorize a duplicate payment for the same month. Once the month for which the initial
supplier received payment is over, the alternate supplier can bill for the next continuous month, but the
supplier of the equipment left behind in the patient's home cannot be paid.
I-10 Question: A number of patients have chosen to remain at home without power even though they are using
mechanical ventilators (HCPCS codes E0465 & E0466) and Respiratory Assist Devices. Supporting these life-
sustaining devices requires supplemental external batteries to maintain the respiratory devices to continue
to function and support the respiratory needs of the patients. Can suppliers bill for supplemental batteries to
support these devices for patients residing in the federally-declared emergency or major disaster area?
Answer: No. The statute does not allow payment for power generators or alternative power sources needed
in the event of power outages.
I-11 Question: Due to flash flooding, beneficiaries needed to leave their homes quickly and were unable to
transport their hospital bed to the new location. These beneficiaries’ medical needs require the support and
position from a hospital bed. Can the supplier bill for both the primary hospital bed and the secondary
temporary replacement hospital bed until the beneficiary is able to return to their home?
Answer: The alternate supplier of the hospital bed needs to seek payment from the supplier that received
the Medicare monthly rental payment amount for the remainder of the paid month during which the
beneficiary relocated or needed to obtain services from an alternate supplier. The Medicare fee-for-service
program does not authorize a duplicate payment for the same month. Once the rental month for which the
initial supplier received payment is over, the alternate supplier can bill for the next continuous month, but
the supplier of the equipment left behind in the patient's home cannot be paid.
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I-12 Question: Where can beneficiaries learn more about disaster resources in areas impacted by a federally
declared emergency or natural disaster?
Answer: Beneficiaries can review a broad range of information at the FEMA website
https://www.fema.gov/disasters. Additionally, beneficiaries should review information and follow instructions
provided by their State or territory for a particular emergency or disaster.
J – End Stage Renal Disease (ESRD) Facility Services
Question Question and Answer
Number
J-1 Question: Will a hospital be reimbursed for dialysis services performed on an emergency basis if the hospital
does not have a hospital-based renal dialysis center?
Answer: Yes. When an ESRD patient cannot obtain his or her regularly scheduled dialysis treatment at a
certified ESRD facility and has a medical need to receive an unscheduled or emergency dialysis session in an
outpatient hospital setting, the service is payable under the outpatient prospective payment system. The
hospital bills under the appropriate revenue code center for HCPCS G0257: UNSCHEDULED OR EMERGENCY
DIALYSIS TREATMENT FOR AN ESRD PATIENT IN A HOSPITAL OUTPATIENT DEPARTMENT THAT IS NOT
CERTIFIED AS AN ESRD FACILITY.
The provisions of payment for this service are applicable to dialysis performed following or in connection with
a vascular access procedure, dialysis performed following treatment for an unrelated medical emergency, and
emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the
hospital to receive payment. Generally, CMS will monitor the use of HCPCS code “G0257” to ensure that
certified dialysis facilities are not incorrectly using this code and that the same dialysis patient is not
repeatedly using this code, which would indicate routine dialysis treatment. As a result of an
emergency/disaster, however, CMS understands that the unscheduled or emergency dialysis treatment may
be necessary for a longer period of time than under otherwise normal circumstances. Hospital outpatient
departments may continue to provide this service on an emergent or unscheduled basis, absent any
functional, nearby, certified dialysis facility to perform the service. For validation purposes, hospitals should
include the condition code “DR” (disaster related) on the claim. In addition, the ESRD patient’s home facility
would be responsible for obtaining and reviewing the patient’s medical records to ensure that appropriate
care was provided in the hospital and that, to ensure continuity of care, any necessary modifications are
made to the patient’s plan of care upon the patient’s return to the facility.
J-2 Question: Dialysis providers are required to maintain a Blood Urea Nitrogen (BUN) test weekly on
hemodialysis, CCPD patients, and monthly for CAPD home patients. The dialysis provider receiving patients
from emergency/disaster-impacted areas may not have this information on hand to bill. What guidance can
be given to providers for this situation?
Answer: The provider should bill using the latest BUN results available which may be the one taken at the
time of treatment. Additional instructions may be found in the Medicare Claims Processing Manual, IOM 100-
4, Chapter 8, Section 50.9, which provides instructions about coding for the adequacy of hemodialysis, as
measured by the Urea Reduction Ratio (this section also includes information about the use of modifier “G6”
for ESRD patients for whom less than seven dialysis sessions have been provided in the month).
J-3 Question: If a hospital has more inpatient dialysis patients than it is equipped to dialyze but there is a
functional outpatient dialysis center nearby to which the hospital sends its inpatients, can both providers bill
Medicare?
Answer: No. If a hospital inpatient is sent to a functional outpatient dialysis unit nearby, that service should
be performed “under arrangements” with the hospital. When services are provided under an arrangement,
the first facility retains the professional responsibility for those services and also for obtaining reimbursement
for them. The second facility is permitted to seek payment only from the first facility and may not bill the
patient or the Medicare program. Hence, under the scenario posed above, the hospital inpatient bundling rule
would apply, and the hospital should bill for the inpatient stay and dialysis service.
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J-4 Question: Value codes “A8” and “A9” are required to be reported on each dialysis claim to report the patient
height and weight. The payment for the claim is determined by this information. Given emergency/disaster
situations, this information may not be gathered and on hand for billing. Can billing guidance be provided?
Answer: This information is necessary for the Medicare system to pay the claim. The height and weight
must be reported. Absent the tools to precisely determine the height and weight the provider may use the
height and weight as reported by the patient from their last session. For patients impacted by the
emergency/disaster, clinically appropriate estimates of weight and height would be acceptable when usual
methods are not available. Documentation of the height and weight should be included in the patient’s
medical records including a description of any alternative methods used as a result of the circumstances. If
the height and/or weight were not obtained because of emergency/disaster-related conditions, the provider
may submit a claim for the first treatment that does not include the height and/or weight. Include on the
claim the condition code DR (disaster related). The FI or MAC will populate the height and/or weight values
using the latest information available in the claim’s history. In 81 FR 64043, language contained in
494.62(b)(4) notes that in emergency conditions, medical documentation for ESRD Facilities should include
the following: Emergency policies and procedures should include a system of medical documentation that is
readily available while protecting the confidentiality of patient information. The system of medical
documentation should support continuity of care, whether in the affected ESRD facility or in a receiving
facility, in the event the patient is transferred. These policies and procedures should supplement existing
medical record requirements and regulations. These policies and procedures should also be in compliance with
the Health Insurance Portability and Accountability Act (HIPAA).
K – Home Health Services
Question Question and Answer
Number
K-1 Question: How will payments be processed for home health agencies (HHAs) in an emergency or disaster?
Answer: In the event of an emergency or disaster, CMS will advise the RHHIs or MACs to facilitate payment
for home health services for beneficiaries who have been displaced due to the emergency/disaster. The RHHI
or MAC will work with the HHAs that have transferred or received patients to ensure that claims are processed
timely, and issues are addressed quickly.
K-2 Question: Can the “residence” component of the homebound requirements be suspended by allowing the
delivery of home health services at any site of temporary residence during an emergency or disaster? Can
this include a residence that is a nursing facility or hospital provided the patient is otherwise not at such level
of care when the patient is using the facility as a medical shelter?
Answer: The Social Security Act stipulates that beneficiaries must be confined to the home in order to be
eligible to receive home health services. A beneficiary’s home is any place in which a beneficiary resides that
is not a hospital, skilled nursing facility (SNF), or nursing facility as defined in § 1861(e)(1), § 1819(a)(1), or
§ 1919(a)(1) of the Social Security Act, respectively. Under the temporary, extraordinary circumstance of a
declared emergency or disaster, place of residence can include services provided at temporary locations like a
family member’s home, a shelter, a community facility, a church, or a hotel. A hospital, SNF, or nursing
facility as defined above would not be considered a temporary residence.
K-3 Question: Can the application of Partial Episode Payment (PEP) be suspended for patients displaced to other
home health agencies (HHAs) due to an emergency?
Answer: Normal prospective payment procedures will apply. We believe it crucial that home health agencies
remain responsible for home health beneficiaries, up until a PEP situation is determined. The PEP
appropriately truncates the previous episode and allows for a subsequent episode to be established with each
home health agency being reimbursed for the services provided.
K-4 Question: Can consolidated billing requirements for home health agencies be suspended during an
emergency for which an 1135 waiver has been issued?
Answer: No. Normal prospective payment procedures apply whether or not an 1135 waiver has been
issued.
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Number
K-5 Question: Our office has been destroyed by disaster. Although we have electronic medical records, some
paper documents including signed Face-to-Face Encounter Forms and Physician Plans of Care have been
destroyed. What documentation does a provider need to have on file to submit as proof of the destruction of
medical records for future ADRs, CERTs, RACs, etc.?
Answer: Instructions for how to handle situations where documentation to support payment has been lost or
destroyed can be found in CMS’ Program Integrity Internet Only Manual in Publication 100-08, Chapter 3, §
3.8 entitled “Administrative Relief from MR During a Disaster” at the following link:
http://www.cms.gov/manuals/downloads/pim83c03.pdf. A note should be entered (and dated) in the medical
record that the documentation of “XYZ” was destroyed in the disaster.
K-6 Question: For Home Health services, how will the requirement for securing physician signatures within 30
days on orders be addressed?
Answer: This is not a Federal requirement but may be State specific. CMS requires a signature prior to billing
the final claim.
K-7 Question: Are the home health requirements for a face-to-face encounter waived under Section 1135 of the
Act?
Answer: No. The required timeframe for the occurrence of a home health face-to-face encounter is typically
flexible enough to allow HHAs to meet this requirement, even in emergency situations. A face-to-face encounter
can occur up to 90 days prior to the start of care or within 30 days after the start of care. (see section 30.5.1.1
in Chapter 7 of the Medicare Benefit Policy Manual (Pub. 100-02)). However, if conditions related to the
emergency cause a provider to expect to be unable to meet these timeframes, that provider should contact the
CMS RO to allow for tracking and completion of this encounter as soon as conditions allow.
K-8 Question: For Home Health services, how will CMS address timely initiation of care when results are collected
for Home Health Compare?
Answer: The information below was posted on the Home Health Consumer Assessment of Healthcare Providers
and Systems (CAHPS) website on Monday, 10/29/12:
The Centers for Medicare & Medicaid Services (CMS) has advised us to alert Home Health Care CAHPS
(HHCAHPS) Survey vendors who are conducting the HHCAHPS Survey by telephone data collection mode to
stop telephone data collection in all states in which there has been a state of emergency declared. All such
vendors should identify the states in which a state of emergency has been declared and stop data collection in
those states until the state of emergency has been lifted. HHCAHPS Survey data collection activities should
resume immediately after the state of emergency has been lifted.
All HHCAHPS Survey vendors located in states impacted by a disaster should notify the HHCAHPS
Coordination Team if your organization stops normal business operations due to the hurricane. All such
agencies should submit a Discrepancy Notification Report describing the number of days your organization
could not conduct HHCAHPS Survey activities due to the disaster, and the date by which you expect to
resume HHCAHPS Survey activities.
Please contact the HHCAHPS Coordination Team by email (HHCAHPS@RTI.org) or by calling (866) 354-0985 if
you have any questions about this issue.
K-9 Question: For a Home Health Agency that is adversely affected by a disaster or emergency, can an
extension be granted for Additional Documentation Requests (ADRs) and/or audit responses?
Answer: In the event of a disaster, Medicare Administrative Contractors and Recovery Audit Contractors
are authorized to grant administrative relief per Chapter 3 § 3.8 of the CMS Program Integrity Manual (Pub.
100-08), “Administrative Relief from Medical Review During a Disaster”. In addition, Medicare medical review
contractors have the discretion to grant extensions to providers who need more time to comply with
additional documentation requests for good cause. Good cause means situations such as natural disasters,
interruptions in business practices, or other extenuating circumstances that the contractor deems to be a
good cause for the provider’s delay in providing documentation.
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L – Hospice Services
Question Question and Answer
Number
L-1 Question: What is a hospice agency’s responsibility in the event of a disaster?
Answer:
All Medicare certified hospices are required to comply with the emergency preparedness Condition of
Participation at §418.113. This CoP requires all hospices to comply with all applicable Federal, State, and local
emergency preparedness requirements, and establish and maintain an emergency preparedness program that
meets the requirements of this CoP. The emergency preparedness program must include, but not be limited
to, the following elements:
(a) Emergency plan. The hospice must develop and maintain an emergency preparedness plan that must be
reviewed and updated at least every 2 years. The standard outlines additional items that must be included in
the plan.
(b) Policies and procedures. The hospice must develop and implement emergency preparedness policies
and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at
paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies
and procedures must be reviewed and updated at least every 2 years. The standard outlines additional items
that must be included in the policies and procedures.
(c) Communication plan. The hospice must develop and maintain an emergency preparedness
communication plan that complies with Federal, State, and local laws and must be reviewed and updated at
least every 2 years. The communication plan includes additional requirements outlined int this standard.
(d) Training and testing. The hospice must develop and maintain an emergency preparedness training and
testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk
assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and
the communication plan at paragraph (c) of this section. The training and testing program must be reviewed
and updated at least every 2 years.
(e) Integrated healthcare systems. If a hospice is part of a healthcare system consisting of multiple
separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness
program, the hospice may choose to participate in the healthcare system's coordinated emergency
preparedness program. The integrated healthcare systems standard, if elected, also includes additional
requirements outlined in the standard.
L-2 Question: If a hospice provider cannot provide care for its patients, can these patients transfer to another
hospice provider?
Answer: Under the Social Security Act at § 1812(d)(2)(C) and CMS regulations at 42 C.F.R. § 418.30(a), a
Medicare beneficiary may transfer from one hospice agency to another hospice for any reason once per
election period. If a Medicare beneficiary has already utilized this one-time right to transfer but needs to
move again because of a public health emergency, § 1861(dd)(5)(D) of the Act provides for a hospice agency
to arrange with another hospice for the delivery of services in extraordinary circumstances. We would not
deem a change in hospice under these circumstances to be a voluntary transfer under 42 C.F.R. § 418.30
(i.e., the beneficiary would still be entitled to a voluntary transfer after a transfer for “extraordinary
circumstances”).
L-3 Question: In the event that the originating hospice is able to resume provision of services to their patients,
should patients be transferred back to the originating hospice?
Answer: CMS believes that patients should be provided with the choice of resuming care from the
originating hospice or continuing with the existing hospice provider. If the beneficiary remains with the
“host”/replacement hospice at the end of the emergency period, we would consider this a transfer under our
regulations at 42 CFR § 418.30. If a beneficiary uses the services of an alternate hospice agency for a short
period of time under arrangement with the patient’s “home” hospice due to extraordinary circumstances,
neither the departure from nor return to the original hospice agency would be considered a “transfer” within
the meaning of 42 CFR § 418.30.
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L-4 Question: How should a hospice that temporarily receives a patient from another hospice handle
administration of that patient’s care plan if the patient arrives with no alternate caregiver information, and/or
the admissions officer believes that the patient may be legally incompetent to make health care decisions for
him/herself?
Answer: Under CMS rules, the health and safety of the patient always comes first. The receiving hospice
should complete an assessment of the patient to identify immediate needs and establish a plan of care with
the interdisciplinary group (IDG). The receiving hospice should make every effort to contact the original
hospice and/or attending physician to discuss the previously implemented plan of care and, if necessary, to
determine if the patient is legally competent. If the receiving hospice has access to the plan of care
established by the original hospice every attempt should be made to follow the plan if the needs of the patient
are such that the original plan will provide the appropriate interventions.
L-5 Question: Who can speak/sign paperwork on behalf of the patient (including discharge and transfer
decisions)?
Answer: A person’s legal authority to make healthcare decisions on behalf of another is a matter of State
law; hospices should confer with their counsel to determine whether their State law has provisions which
address health care decision-making in emergency/extraordinary circumstances. If the hospice patient
cannot speak or sign paperwork, the receiving hospice should make arrangements to get permission for
treatment and care pursuant to state requirements.
L-6 Question: In the event of an emergency, will hospice inpatient and aggregate payment caps be waived?
Answer: Because these caps are not conditions of participation or program participation provisions within
the meaning of § 1135 of the Act, no statutory authority exists to allow CMS to waive these payment caps.
L-7 Question: If a hospice patient is transported out of the impacted area due to emergency evacuation by
ambulance and admitted to Hospice Inpatient Respite Care several hours away for safety, who is responsible
for the ambulance bill to the destination and the return trip?
Answer: The emergency waiver authority under § 1135 of the Social Security Act (Act) does not affect how
Medicare hospice services are covered. Specifically, as in non-emergency situations, those services and items
covered pursuant to §1861(dd)(1)(I) of the Act (which authorizes coverage of “any other item or service
which is specified in the plan of care and for which payment may otherwise be made…”) would continue to be
covered pursuant to existing standards of coverage and payment. Generally speaking, if the ambulance
transport was medically necessary, and if the patient's plan of care described that the patient's terminal
illness required ambulance transport, the hospice would be responsible for the ambulance bill. In a scenario
where ambulance transport arrangements are made by a patient’s family, and the ambulance transport needs
are not documented in the hospice plan of care, the patient would be responsible for the ambulance bill.
L-8 Question: A hospice has been putting some of its patients in a facility for respite care (due to no heat,
electricity, etc.) and is worried about going beyond the five-day limit. Can the 5-day limit be waived?
Answer: CMS has no authority to extend the hospice respite limit beyond 5 days. For the 6th and
subsequent days, the hospice should bill for routine home care (RHC) and the beneficiary would be liable for
room and board. The Federal Emergency Management Agency (FEMA) and/or the State may be able to assist
with room and board costs, but room and board cannot be paid out of the Medicare Trust Fund when a home
level of care is provided.
L-9 Question: Are the hospice requirements for a face-to-face encounter waived under Section 1135 of the Act?
Answer: No. The required timeframe for the occurrence of a hospice face-to-face encounter is typically flexible
enough to allow hospices to meet this requirement, even in emergency situations. A face-to-face encounter can
occur up to 30 days prior to the start of the third benefit period and 30 days prior to any subsequent benefit
periods thereafter (see section 20.1 in chapter 9 of the Medicare Benefit Policy Manual (Pub. 100- 02)).
However, if conditions related to the emergency cause a provider to expect to be unable to meet these
timeframes, that provider should contact the CMS RO to allow for tracking and completion of this encounter as
soon as conditions allow.
L-10 Question: For Hospice, how will timing of the certification of terminal illness (CTI) be addressed in an
emergency situation?
Answer: We have no authority to change or waive any CTI requirements. A hospice can continue to get a
verbal certification of terminal illness for new admissions and must complete the written certification before
filing the claim.
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L-11 Question:
Question: For Hospice, how will the general inpatient care (GIP) visit requirement be addressed in an
emergency situation?
Response: The Emergency Preparation (EP) CoP at 42 CFR 418.113(b) requires hospices to develop an EP
program that includes an emergency plan, policies and procedures, communication plan and training and
testing. Documentation of patient care would follow the hospices own policies and procedures including the
hospices EP plans. The EP policies and procedures standard consist of the following requirements:
(b) Policies and procedures. The hospice must develop and implement emergency preparedness policies and
procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at
paragraph (a)(1) of this section, and the communication plan at paragraph (c)of this section. The policies and
procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures
must address the following:
(1) Procedures to follow up with on-duty staff and patients to determine services that are needed, in the event
that there is an interruption in services during or due to an emergency. The hospice must inform State and
local officials of any on-duty staff or patients that they are unable to contact.
(2) Procedures to inform State and local officials about hospice patients in need of evacuation from their
residences at any time due to an emergency situation based on the patient's medical and psychiatric condition
and home environment.
(3) A system of medical documentation that preserves patient information, protects confidentiality of patient
information, and secures and maintains the availability of records.
(4) The use of hospice employees in an emergency and other emergency staffing strategies, including the
process and role for integration of State and Federally designated health care professionals to address surge
needs during an emergency.
(5) The development of arrangements with other hospices and other providers to receive patients in the event
of limitations or cessation of operations to maintain the continuity of services to hospice patients.
(6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies
and procedures must address the following:
(i) A means to shelter in place for patients, hospice employees who remain in the hospice.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees;
staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means
of communication with external sources of assistance.
(iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter
in place, include, but are not limited to the following:
(A) Food, water, medical, and pharmaceutical supplies.
(B) Alternate sources of energy to maintain the following:
(1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions.
(2) Emergency lighting.
(3) Fire detection, extinguishing, and alarm systems.
(C) Sewage and waste disposal.
(iv) The role of the hospice under a waiver declared by the Secretary, in accordance with section 1135 of the
Act, in the provision of care and treatment at an alternate care site identified by emergency management
officials.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care
during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the
hospice must document the specific name and location of the receiving facility or other location.
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L-12 Question: If a hospice patient has been moved from his private home to a facility due to a disaster/emergency,
who is responsible for room and board costs? Should the hospice bill the GIP rate or the respite rate? What
happens when the patient’s 5-day respite limit has been exceeded? If the patient’s home is still without power,
or is damaged, or otherwise not usable after the 5 days of respite, should the hospice revoke the patient?
Answer: We have no authority to extend the respite limit beyond 5 days. A hospice patient receiving routine
home care (RHC) at home who moves to a facility can receive respite care for up to 5 days. The hospice is
responsible for paying the facility for the room and board during the 5 days of respite, based on its
agreement with that facility. For the 6th and subsequent days, the hospice should bill routine home care, and
the beneficiary would be liable for room and board. The Federal Emergency Management Agency (FEMA)
and/or the State may assist with room and board; room and board cannot be paid out of the Medicare Trust
Fund when a home level of care is provided.
GIP is not justified simply because the home lacks power or is damaged; in the fiscal year (FY) 2008 hospice
wage index final rule, we wrote, “To receive payment for general inpatient care under the Medicare hospice
benefit, beneficiaries must require an intensity of care directed towards pain control and symptom
management that cannot be managed in any other setting. It is the level of care provided to meet the
individual’s needs and not the location of where the individual resides, or caregiver breakdown, that
determine payment rates for Medicare services.” (72 FR 50220).
A hospice cannot revoke the hospice benefit for a beneficiary; only a beneficiary can revoke the hospice benefit.
L-13 Question: In emergency circumstances, can Hospice providers be forgiven for late filing of a Notice of
Election (NOE)?
Answer: Our regulations at 42 CFR 418.24(a)(4), and Chapter 9, section 20.2.1.3 of the Medicare Benefit
Policy Manual provides the exceptions to the timely filing requirement for the hospice Notice of Election
(NOE). There are four circumstances that may qualify the hospice for an exception to the consequences of
filing the NOE more than 5 calendar days after the effective date of election and one of those exceptions
includes fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s
ability to operate. The hospice must document the circumstance to support a request for an exception, which
would waive the consequences of filing the NOE late. Using that documentation, the hospice’s Medicare
contractor will determine if a circumstance encountered by a hospice qualifies for an exception to the
consequences for filing a NOE more than 5 calendar days after the effective date of election. Please refer to
Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, “Processing Hospice Claims” for requirements
for NOE submission, reporting provider-liable days, and qualifying circumstances for a request for exception.
M – Hospital Services – General
Question Question and Answer
Number
M-1 Question: Beneficiary was scheduled for surgery and all pre-op testing was completed, but due to a disaster
the scheduled hospital was unable to perform the surgery. Can the beneficiary have the surgery at another
hospital? Will the beneficiary have to repeat the pre-op test?
Answer: If the physician has re-established his practice near the beneficiary, the beneficiary can contact
him/her at the new location. However, if you cannot locate your physician, you will need to see another
physician who will want to perform his/her own evaluation. If the test results are available, repeat tests may
not be necessary. If the test results are not available, they will need to be repeated. A new physician may
also have differing criteria as to who is eligible for surgery. Those criteria do vary among health care
providers.
M-2 Question: Patients are taken to a second facility for chemotherapy services because of inadequate staff at
the original facility due to the emergency. How should this be billed?
Answer: For inpatients, the originating hospital must bill for these services as part of the original inpatient
stay and is responsible for reimbursing the second facility for the chemotherapy services provided “under
arrangements.” This is necessary so that claims are not submitted with overlapping dates of service. If the
originating hospital is not able to operate and discharges the patient, the receiving facility may bill Medicare,
beginning with the date they assumed responsibility for the inpatient. If the services were rendered in an
outpatient setting at both facilities, both facilities may bill for their own services as long as the dates of
services do not overlap. Specifically, each facility may bill for the particular dates on which they serviced the
beneficiary by providing chemotherapy. All facilities need to use the specific line item dates of service for
each beneficiary encounter.
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M-3 Question: If a hospital inpatient is evacuated to an undisclosed location due to an emergency, what Patient
Status (PS) Code should I use on the bill?
Answer: Given the unknown location of the patient, it would be acceptable for any type of discharging
hospital (inpatient acute, inpatient psychiatric, inpatient rehabilitation, long term care, children’s, cancer,
critical access, etc.) to code PS Code “01”, Discharged to home/self-care, in this situation. The following
system edits and automatic adjustment processes are in place to help ensure that final payment amounts to
providers are correct.
∙ If the patient was in an acute care hospital, was evacuated (discharged) to an undisclosed location and
was subsequently admitted to another inpatient acute care hospital, then the first bill will be automatically
adjusted with the PS “02” to pay as if the patient was transferred to another acute care hospital.
∙ Similarly, if the patient was in an acute care hospital and was subsequently admitted to a Skilled Nursing
Facility (SNF), Home Health Agency (HHA) or other facility that causes the first hospital to be subject to
the post-acute care transfer payment methodology, when the subsequent provider submits its bill, the bill
from the first provider will be automatically adjusted to pay as if the patient was transferred to the
subsequent facility.
∙ If a patient was in a long-term care hospital and was evacuated (discharged) to an undisclosed location,
the payment to the long-term care hospital would be subject to the short stay outlier payment
methodology if the length of stay prior to the evacuation warranted that payment adjustment.
M-4 Question: What special considerations will CMS provide on calculating the wage index subsequent to an
emergency or disaster? There would be aberrant wage data for the period after the emergency/disaster hit.
Answer: If an emergency or disaster were to occur, any changes in labor costs that a hospital might incur to
address the situation would not be recognized in the wage index until at least 4 years later. This is the
amount of time that is generally required for the universe of hospitals’ cost reports from any wage index base
year to be collected and reviewed by CMS. This time frame also provides for a process for hospitals to review
and correct their data before it is used in computing the final wage index. Therefore, until the entire wage
index development process is completed, neither CMS nor any affected hospitals would have an accurate and
objective way of estimating any changes in affected hospitals’ labor costs related to the emergency/disaster
or of predicting what effect any changes in their labor costs will have on the wage index.
M-5 Question: When a teaching hospital, located in a declared emergency/disaster area, receives residents from
teaching hospitals located outside the declared emergency/disaster area to provide care, can the receiving
hospital count the additional residents for purposes of indirect medical education (IME) and direct graduate
medical education (GME) payment?
Answer: CMS issued an interim final rule with comment period (CMS-1531-IFC, which appeared at 71 FR
18654, April 12, 2006) in order to provide teaching hospitals in certain emergency situations the ability to
temporarily transfer their IME and direct GME FTE resident cap positions to any hospital in the country
through Emergency Medicare GME Affiliation Agreements when a section 1135 waiver is in effect. Currently,
the provisions in CMS-1531-IFC address emergency situations in which a hospital in an emergency area must
find alternate training sites for its displaced residents -- generally to hospitals located outside of the
emergency area. However, absent a section 113 waiver, unless a regular (non-emergency) Medicare
affiliation could be used to add cap positions to the affected hospital from another hospital, given the existing
statutory caps, the regulations do not provide for a temporary adjustment to the affected hospital’s FTE caps
to the extent needed to allow the hospital to count the additional residents for IME and direct GME payment
purposes.
M-6 Question: If a teaching hospital affected by the emergency temporarily loses some or all of its residents for
a period of time due to the emergency, what will be the effect on calculating direct and indirect graduate
medical education (GME) payments?
Answer: The Medicare statute requires that a hospital is paid in the current year based on a three-year
“rolling average” count of residents; that is, the average of the number of residents in the current year and
two prior years. This is a statutory requirement intended to distribute the impact of increasing or decreasing
the number of residents at a hospital over a three-year period. Thus, if a hospital temporarily loses some or
all of its residents for a period of time due to an emergency, the hospital would still be able to receive IME
and direct GME payments because the effect of decreasing the number of residents at the hospital will be
spread over a three-year period.
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Number
M-7 Question: How should the following situation be handled relative to Medicare billing? Hospital “A” is
evacuated due to a declared emergency and patients are sent to hospital “B”. These same patients are later
moved to a shelter because hospital “B” is now forced to evacuate because of the emergency.
Answer: In this scenario, Hospital “A” has sent the patient to Hospital “B.” Although not stated in the
question, the implication is that the patient has been formally released by Hospital “A” to Hospital “B” and
therefore is treated as having been discharged from Hospital “A” and transferred to Hospital “B”. In this
scenario, Hospital “A” would discharge the patient and reflect a transfer to Hospital “B” indicating the
appropriate patient status (from locator 17 of the UB-04):
02 – if transferred to another acute care facility (PPS);
03 – if transferred to a SNF;
04 – if transferred to a nursing home not considered a skilled facility;
05 – if transferred to a Cancer or Children’s Hospital;
62 – if transferred to an Inpatient Rehab Facility (IRF);
63 – if transferred to a Long Term Care Hospital (LTCH);
65 – if transferred to a Psychiatric Facility;
66 – if transferred to a Critical Access Hospital; or
70 – if transferred to another type of facility not defined on the list.
Assuming that Hospital “B” will be receiving the patient back due to their medical condition still warranting
acute medical care, Hospital “B” would reflect the admission date from Hospital “A” as the actual date of
patient receipt and would reflect the days absent in a non-medical facility as furlough/leave of absence days
and continue their care upon return of the patient.
M-8 Question: Can CMS clarify its waiver authority, especially about having federal nurses come to the hospital
and help with staffing issues. Can those services be unbundled so that hospitals can bill Medicare? \
Answer: Hospitals should bill Medicare as they normally would for inpatient or outpatient services even
when such services included the volunteered professional services of a registered nurse. Medicare does not
allow for these services to be unbundled and billed.
The Medicare hospital Conditions of Participation (CoPs) require that non-employed registered nurses working
in the hospital must adhere to the hospital’s policies and procedures and must be adequately supervised and
evaluated. The hospital must also verify that the nurse holds a current license.
M-9 Question: We have a Medicare patient receiving inpatient psychiatric hospital services that can't be placed
in the distinct part psychiatric unit because all patients are quarantined (for example, due to the flu). Can we
still bill under the inpatient psychiatric unit’s provider number even though they are in an acute bed?
Answer: If the patient is not in the IPPS-excluded distinct part psychiatric unit, even if the patient is
receiving inpatient psychiatric hospital services, and as long as the placement of the patient in the hospital’s
acute care bed is not inappropriate to his/her condition, the hospital will receive IPPS payment for that
patient's care. Billing under the inpatient psychiatric unit’s provider number is not allowed.
M-10 Question: During an emergency, will Medicare fee-for-service allow payment for care provided at a site not
considered part of the facility (which are informally termed “alternative care sites” (ACSs)) for patients who
are not critically ill? For example, if local hospitals are almost at capacity during an emergency and the few
beds remaining must be reserved for patients needing ventilators and critical care, will Medicare fee-for-
service pay for non-critical care provided at an ACS, such as a school gymnasium?
Answer: Normally an ACS would require the issuance of waivers under section 1135 in order to operate. In
the absence of an 1135 waiver, a hospital may add a remote location that provides inpatient services to the
hospital’s Medicare certified beds under its existing provider agreement, provided that the remote location
satisfies the requirements to be provider-based to the hospital’s main campus (including being located within
35 miles pursuant to 42 CFR 413.65(e)(3)). The remote location must satisfy all provider-based
requirements including being compliant with the hospital Conditions of Participation (CoPs). The hospital
would be expected to file an amended Form CMS 855A with its Medicare Administrative Contractor as soon as
possible adding an additional location. CMS generally requires a survey of compliance with all CoPs at all new
inpatient locations, but also has discretion to waive the onsite survey in this area.
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Question Question and Answer
Number
M-11 Question: If a patient is taken to a second facility for chemotherapy services because the equipment at the
original hospital is not operating, how should these services be billed?
Answer: If the patient was an outpatient at both hospitals, the first hospital would bill for the covered
outpatient department (OPD) services it provided while the beneficiary was its outpatient. Once the
beneficiary ceased to be the first hospital’s outpatient and he/she became the second hospital’s outpatient,
the second hospital would bill for any covered OPD services it provided.
If the patient at the first hospital was an inpatient and was not discharged prior to receiving chemotherapy
services, the originating hospital may provide the chemotherapy services under arrangement with the second
facility and must bill for these services as part of the original inpatient hospital stay and reimburse the second
facility for the chemotherapy services provided “under arrangement.” The second hospital may not bill
Medicare directly for any services in this situation.
Alternatively, if the first hospital discharged or transferred the patient, it would bill for the inpatient services it
provided and the case would be paid the applicable IPPS payment (subject to the transfer policy if the patient
was transferred and treated as inpatient at the second hospital). If the patient is treated as an inpatient by
the second hospital, it would bill for the inpatient services it provided and be paid the applicable IPPS
payment (subject to the transfer policy, as applicable, based on the patients discharge destination). If the
patient is discharged from the first hospital and treated as an outpatient at the second hospital, the second
hospital would bill for the outpatient services it provided.
M-12 Question: Will CMS provide for “cost based” reimbursement for loss on disposal of depreciable assets for
directly affected providers?
Answer: Losses resulting from the involuntary conversion of depreciable assets that occurred due to a
declared emergency or disaster are includable in the allowable costs of providers (42 CFR § 413.134(f)(6). P
Critical Access Hospitals (CAHs) and Rural Health Clinics (RHCs),) are paid under reasonable cost for
Medicare’s share of these allowable costs or a portion of a blended prospective payment under 42 CFR §
412.348(f). For providers paid under their respective Federal PPS rate (e.g., SNFs, IRFs, IPFs, LTCHs, HHAs,
FQHCs, ESRD facilities, short-term acute care IPPS hospitals), where payments are bundled, there would be
no mechanism to independently pay for disposable depreciable assets under reasonable cost. In the case
where there is a Capital IPPS extraordinary circumstance exception (per 42 CFR § 412.348(f)) for short-term
acute care IPPS hospitals, those costs may be includable in the allowable costs upon which the exception
payment will be based.
M-13 Question: Are there any additional payments for hospitals’ capital costs as a result of the unanticipated
capital expenditures they face due to a declared emergency or disaster?
Answer: Under the existing regulations for short-term acute care hospitals under the Inpatient Prospective
Payment System (IPPS) (see 42 CFR § 412.348(f)), there is an Extraordinary Circumstances Exception
provision under the Capital IPPS that provides an additional payment if a hospital incurs unanticipated capital
expenditures in excess of $5 million (net of proceeds from other funding sources, including insurance,
litigation, and government funding (e.g., FEMA aid)) due to extraordinary circumstances beyond the hospital’s
control (such as a hurricane, flood, or other declared emergency or disaster). For most hospitals, the
additional payments are based on 85 percent of Medicare's share of allowable inpatient capital costs
attributed to the extraordinary circumstance (100 percent for sole community hospitals). There may be an
offset to this amount based on a comparison of the hospital’s cumulative Capital IPPS payments to a specified
percent of its Medicare allowable costs over the past 10 years.
M-14 Question: How do Inpatient Prospective Payment System (IPPS) hospitals apply for the Capital IPPS
Extraordinary Circumstances Exception payments?
Answer: To receive payments under the Capital IPPS Extraordinary Circumstances Exception provision, a
hospital that may be eligible for such payments must make a written request to its CMS Regional Office (RO)
within 180 days after the occurrence of the extraordinary circumstance causing the unanticipated
expenditures for a determination by CMS. If necessary, additional supporting information and documentation
may be sent after the 180-day period provided that an initial written request was made to the appropriate RO
in a timely manner. A complete written request should include an explanation with supporting documentation
of the circumstances that led to the unanticipated capital expenditure, the estimated amount of the
expenditure and the sources and amounts of any anticipated reimbursement from other sources (including
insurance, litigation and government funding (e.g., FEMA)) directly related to the capital expenditure. The RO
will evaluate the completed request and forwards its recommendation to the Administrator for a decision
based on the nature of the circumstances, any recovered proceeds from other parties and the amount of
financial loss documented by the hospital.
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M-15 Question: Can appeal rights be waived in the absence of an 1135 Waiver?
Answer: CMS cannot waive this beneficiary protection. However, in declared emergencies we asked the
Quality Improvement Organization (QIO) to expedite these appeals to ensure that hospitals may timely
discharge these patients while still affording them protection from inappropriate discharge.
M-16 Question: A facility has taken in patients, has them under observation, and is providing them with
oxygen. The facility is stating that it is a safety hazard to discharge patients because they have no electricity
and are unable to access their oxygen which is noted on their charts. The provider wants to know how to bill
their claims.
Answer: If the facility is providing observation services consistent with the CMS definition of observation in
the Medicare Benefit Policy Manual, Chapter 6, Section 20.6, then the facility can bill Medicare for observation
services, whether or not the facility provides oxygen as a part of the services provided to the patient.
M-17 Question: For Medicare patients admitted to a hospital (including post-acute care due to a declared
emergency, who exhaust their Medicare Part A benefit, will CMS extend Part A coverage and payment for the
duration of a declared emergency related admission?
Answer: Medicare does not have the authority to extend Part A coverage for those that have exhausted
their benefit, but we would note that the Social Security Act (Section 1812) provides beneficiaries with 60
nonrenewable lifetime reserve days from which a beneficiary can draw upon if hospitalized for more than 90
days in a benefit period.
N – Hospital Services – Emergency Medical Treatment and Labor Act (EMTALA)
Question Question and Answer
Number
N-1 Question: Evacuees from States affected by the public health emergency may arrive at hospital emergency
departments merely to obtain refills of prescriptions that they lost when they evacuated during a disaster or
public health emergency. Must these individuals be given an EMTALA medical screening examination when
they come to the emergency department?
Answer: Even under non-emergency circumstances, the Emergency Medical Treatment and Labor Act
(EMTALA) regulations make it clear that individuals seeking examination or treatment for a medical condition
(e.g. prescription refills) need not be given a complete medical screening examination, but rather, an
appropriate medical screening examination (MSE) that is for the request that they make in order to determine
that an EMC does not exist. Hospitals may wish to develop specific protocols that include a streamlined
screening examination for individuals seeking prescription refills, consistent with the EMTALA regulations at
42 CFR § 489.24. For additional information on all EMTALA requirements, please see Appendix V -
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_v_emerg.pdf
N-2 Question: Is it permissible for a hospital to triage individuals with suspected cases of an infectious disease
to an alternative site for evaluation under EMTALA? If so, how do we bill for these services?
Answer: Under current Emergency Medical Treatment and Labor Act (EMTALA) law and regulations,
hospitals are permitted to move individuals out of their dedicated emergency departments to another part of
the hospital (on the hospital’s same campus) in order to provide the required appropriate MSE and then, if an
emergency medical condition is found to exist, to provide stabilizing treatment or arrange for an appropriate
transfer. Sometimes hospitals refer to these as “fast-track clinics” and use them either all year round or
during surge in demand for emergency department services during the seasonal cold and flu season. The
MSE provided in the “clinic” must be performed consistent with the requirements of the EMTALA provision, by
qualified medical personnel who can perform an MSE that is appropriate to the individual’s presenting signs
and symptoms.
If, prior to directing the individual elsewhere in the hospital, qualified medical personnel in the emergency
department completed an appropriate MSE and determined that the individual does not have an emergency
medical condition, then the hospital has no further EMTALA obligation to that individual and the issue of
moving the individual to an alternate site, either on or off the hospital’s campus, would be moot from an
EMTALA perspective.
For services rendered to Medicare fee-for-service (FFS) beneficiaries, standard Medicare FFS billing rules
apply. Hospitals should work with their other payers to determine if special billing rules may apply.
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N-3 Question: What is CMS’s procedure for addressing requests to waive EMTALA?
Answer: Because each emergency or disaster presents a unique set of circumstances, especially as they
relate to the demand for emergency treatment, CMS calibrates its response to EMTALA-related issues to
coincide with the nature of each emergency. CMS handles these matters on a case-by-case basis. In an
emergency or disaster, CMS, both centrally and through its Regional Offices, will open communications with
affected State governments (especially the State Survey Agencies) and with providers, trade groups, and
other stakeholders to learn about local conditions. In addition, the State survey agencies are responsible for
reporting the status of health care providers affected by the emergency to their CMS Regional Office and CMS
relies upon that information to make recommendations to the Secretary regarding the need for EMTALA
waivers.
N-4 Question: Has HHS issued any § 1135 waivers in the past that specifically address EMTALA?
Answer: Since § 143 of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002
amended § 1135 of the Social Security Act to add the waiver authority, § 1135 waivers have been issued for
Hurricanes Katrina, Rita, Gustav and Ike, for the flooding in Iowa and Indiana during CY 2008, for the
flooding in North Dakota and Minnesota in CY 2009 and for the COVID-19 PHE in 2020. In each emergency
event, sanctions for certain types of EMTALA violations were waived for 72 hours after implementation of an
affected hospital’s disaster protocol. However, if a public health emergency were to involve a pandemic
infectious disease, the Secretary could invoke his or her waiver authority under § 1135 to waive certain
EMTALA sanctions and such an EMTALA waiver would continue in effect until the termination of the applicable
public health emergency declaration (in accordance with § 1135(e)(1)(B) of the Act).
N-5 Question: If a hospital remains open during a disaster, and is operating at or in excess of its normal
operating capacity and cannot get sufficient staff, may the hospital shut down its emergency department (ED)
without violating EMTALA?
Answer: Hospitals are not required under the Medicare Conditions of Participation to operate emergency
departments, and thus always have the option of closing this service, so long as there is no State law
requirement for the hospital to maintain an ED, and so long as the hospital employs an orderly closure
process. Once the hospital no longer has a dedicated emergency department, it no longer has an EMTALA
obligation to provide screening and stabilization to individuals who come to the hospital.
However, if the question is about whether an ED may temporarily refuse to see all new patients, due to
capacity problems, such refusal may not be permitted under EMTALA depending on the circumstances. The
EMTALA regulations do permit hospitals to place themselves on “diversionary” status when they lack the staff
or facilities to accept additional emergency patients, i.e., they may, by phone or other electronic
communications system, advise non-hospital-owned ambulances to go to another hospital. Again, while they
are permitted to do this under EMTALA, their actions must also be consistent with State or local requirements
governing ambulances and hospital diversionary status. However, even in this circumstance, if the
ambulance nevertheless brings an individual onto the property of the hospital on diversion, then the hospital
has an EMTALA obligation to provide an appropriate MSE and, if the individual has an emergency medical
condition, to provide stabilizing treatment.
Furthermore, if a hospital with a dedicated emergency department is operating under a section 1135 waiver,
which includes a waiver under section 1135(b)(3) of the Act, sanctions for the direction or relocation of an
individual to receive medical screening at an alternate location do not apply so long as the direction or
relocation is pursuant to an appropriate State emergency preparedness plan or State pandemic preparedness
plan and the hospital does not discriminate on the individual’s source of payment or ability to pay.
N-6 Question: Emergency Flu Response--We are planning to use an outpatient area of the hospital as an
Emergency Department (ED) extension to see overflow patients from the ED. Can we still bill the ED Levels
for the facility charges (99281 - 99285)? If the physician seeing these patients is not board certified in
Emergency Medicine but is board certified in Family Practice, can the facility bill the ED levels? This question
is only in regard to the OPPS facility-side, not professional billing.
Answer: The hospital may bill CPT codes 99281 through 99285 for emergency visit services furnished in the
outpatient area where this separately identifiable area meets the definition of a Type A emergency
department (ED) (and complies with all other applicable requirements). If the separately identifiable area
operates less than 24 hours per day, 7 days per week for emergency services, and it meets the definition of a
Type B ED (dedicated emergency department that incurred EMTALA obligations, but did not meet the CPT
definition of an ED) (and meets all other applicable requirements), then it may bill emergency visit services
using HCPCS codes G0380 through G0384 as appropriate. The specialty of the physician ordering the
emergency services for hospital outpatients (emergency physician, family medicine, or other) in the area of
the hospital where emergency services are furnished does not affect whether the facility is considered a Type
A or B ED for purposes of billing under the OPPS.
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N-7 Question: Given that EMTALA requires Medicare participating hospitals with emergency departments to
provide certain health care services regardless of individuals’ legal status when they present with emergency
medical conditions, and given that the MMA provided monies under section 1011 of the Act to reimburse
hospitals for services related to EMTALA, would these provisions (EMTALA and section 1011) cover
prophylaxis of contacts (treatment for an individual who has been exposed to a contagious disease) or
vaccination?
Answer: The answer depends on the specific medical circumstances involved. EMTALA requires that if an
individual presents to a hospital with a dedicated emergency department, and requests treatment for a
medical condition, the hospital is required to provide an appropriate MSE to determine if an emergency
medical condition exists. If an emergency medical condition does exist, the hospital is required to provide
necessary stabilizing treatment or provide for an appropriate transfer to another facility. Section 1011
provides reimbursement to eligible providers for services required by or related to EMTALA when furnished to
certain undocumented aliens. Therefore, if an individual who is an undocumented alien (or otherwise eligible
under section 1011) presents to a hospital with a medical condition and requires treatment to stabilize an
emergency medical condition, that treatment would be considered to be an EMTALA-related service and may
be eligible for reimbursement under section 1011. Not all individuals who have been exposed to a
contagious disease or are seeking a vaccination may have an emergency medical condition as that term is
defined under EMTALA. For instance, if treatment is provided that is solely for preventative purposes, that
treatment could not be considered an EMTALA-related service.
O – Hospital Services – Acute Care
Question Question and Answer
Number
O-1 Question: Will a hospital be eligible for additional payment for rendering services to patients that remain in
the hospital due to the fact that they continue to need medical care but at less than an acute level and those
services are unavailable in the area because of the emergency?
Answer: A physician may certify or recertify the need for continued hospitalization if the physician finds that
the patient could appropriately receive a sub-acute level of care such as in SNF, but a sub-acute bed is not
available. In this case, any inpatient days can be counted as “administratively necessary days” until the
Medicare patient can be moved to an appropriate facility and will be paid under the IPPS. Medicare would
count any charges on those days towards determining whether Medicare will make a cost outlier payment. If
the patient is not in need of either an acute level of inpatient care or a sub-acute level of care, any days that
the patient remains in the hospital are not paid for under the IPPS and charges for any services provided on
those days do not count towards determining whether Medicare will make a cost outlier payment.
O-2 Question: Are prospective payment providers going to be paid using a special payment method? If not, is
there a special MS-DRG that IPPS providers will be reimbursed for this situation?
Answer: Normal prospective payment methodologies apply to those hospitals reimbursed under the Inpatient
Prospective Payment System.
O-3 Question: Due to the unexpected emergent nature of the IPPS hospital evacuation, there was not time to
work out a financial arrangement with the receiving health care institution. Are IPPS hospitals responsible for
reimbursing the receiving hospital for full charges or can assistance be provided if problems arise with post
evacuation payment negotiations?
Answer: Financial agreements between providers are a private matter between those two parties. CMS
cannot dictate the terms of these agreements or interfere in providers’ negotiations.
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O-4 Question: How will Medicare pay for an acute care hospital inpatient in Hospital “A” that was evacuated to
another acute care hospital (Hospital “B”) due to an emergency? Will it make a difference if there is a § 1135
waiver for a public health emergency? Will it make a difference if the patient was transferred through the
National Disaster Medical System (NDMS)?
Answer: In general, Medicare’s payment policy for Medicare inpatients will be the same irrespective of
whether there is a § 1135 waiver or the patient was transferred through the NDMS.
Hospital A (the originating hospital) will receive an IPPS payment subject to the acute-to-acute transfer
policy, which may reduce the MS-DRG payment based on the patient’s length of stay. If Hospital B (the
receiving hospital) discharges the Medicare patient, Medicare will pay the full IPPS payment which is not
subject to any reduction under the transfer policy. If Hospital B transfers the Medicare patient, Medicare will
pay the IPPS payment which may be reduced under the transfer policy, as applicable.
For brief evacuations where the patient returns to Hospital A (the originating hospital), a single IPPS payment
is made to Hospital A and payment is made “under arrangement” to Hospital B (the receiving hospital) by
Hospital A. (See question and answer about temporary transfers of patients for more information about
financial arrangements between hospitals.) If the evacuation is expected to be more than brief and there has
been a complete transfer of care from the evacuating hospital (Hospital A) to the receiving hospital (Hospital
B), then each hospital would bill Medicare and receive the IPPS, subject to the transfer policy as applicable.
P – Hospital Services – Critical Access Hospitals (CAHS)
Question Question and Answer
Number
P-1 Question: Will CMS allow CAHs to stock more than 25 beds, to be ready for surge capacity needs, on
campus, without being out of compliance as a CAH, since the beds would not be used except in an
emergency?
Answer: CAHs already have the capability of having extra furniture as long as it is clearly in storage and is
not staffed and ready for use. The CAH bed limit is statutory and would require either a statutory change or a
section 1135(b) waiver to authorize any exceptions. However, under normal circumstances, CMS counts as
part of the 25-bed limit any rooms/spaces that are equipped and clearly ready to be used by simply rolling a
“stored” bed into that space. There is a difference between having warehoused beds that provide the ability
to add surge capacity during a declared emergency and having beds that can be readily used whenever the
CAH wishes to exceed the 25 bed limit. In a clear emergency situation, CMS would notify providers of the
extent to which beds could be moved from storage and readied for use (and not counted).
P-2 Question: Does a Critical Access Hospital (CAH) get paid differently depending on whether it is a new
admission or a transfer of a patient that is evacuated from an area undergoing an emergency?
Answer: No. A CAH will receive 101 percent of reasonable costs for all inpatient services furnished by the
CAH (other than services of distinct part units) irrespective of whether the patient was discharged from a
hospital in an emergency area and then admitted to the CAH or transferred from that hospital.
Q – Hospital Services – Inpatient Rehabilitation Facilities (IRFs)
(Reserved)
R – Hospital Services – Long Term Care Hospitals (LTCHs)
Question Question and Answer
Number
R-1 Question: Can a long-term care hospital (LTCH) be excluded from the application of the site neutral payment
rate?
Answer: The site neutral payment rate cannot be waived without a change in the law, even in a disaster or
emergency.
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S – Hospital Services – Mobile Emergency Hospitals
Question Question and Answer
Number
S-1 Question: Some States are considering utilizing mobile hospitals, based on military field hospital model as a
means of meeting their emergency preparedness needs. Under what scenario could these mobile units be
eligible for Medicare funding?
Answer: It may be possible for a Medicare participating hospital to operate a mobile facility as a part of the
hospital, as long as the mobile unit complies with all the hospital conditions of participation (including the Life
Safety Code) and the provider-based rules (including remaining within 35 miles of the main provider). If the
mobile unit meets the provider-based regulations at 42 C.F.R. § 413.65, then they use the main hospital’s
provider number. If not, then the mobile unit will be treated as a freestanding clinic. CMS will gladly work
with any State wishing to develop mobile capacity. Situations involving use of mobile units will be evaluated
on a case-by case basis.
T – Skilled Nursing Facilities
Question Question and Answer
Number
T-1 Question: Our SNF was affected by an emergency and, as a consequence, some of our patients were
transferred to other providers. We have not submitted claims for the month of the transfer. What is the
correct patient status code that should be used?
Answer: Those affected providers that are aware of the location of their former resident’s transfer should
include the correct patient status code for the transfer (i.e., patient status code “03” = transfer to SNF). If
not aware of the exact transfer, providers should use patient status code “01” (discharged to home or self-
care) in order to bypass any potential overlapping claim situations. Providers should include “declared
emergency” on their remarks page prior to submitting the claim to Medicare.
T-2 Question: Our SNF has received beneficiaries transferred from another SNF provider affected by an
emergency. I have submitted my claims to Medicare for the month after the transfer, but I am receiving an
overlap with the prior month’s claim previously sent by the affected SNF. How can I get my claim paid?
Answer: Receiving providers should make sure they include remarks indicating “declared emergency” on any
claims affected by the emergency. The receiving provider should contact their FI or MAC for assistance with
these overlap situations. FIs and MACs shall identify the overlap and develop the claim accordingly, including
working with other FIs that might service the affected SNF.
If the transferring provider submitted its “transfer-month” claim with a patient status of “30” (still patient)
but the patient was actually transferred in that month, the FI/MAC shall adjust the claim or work with the
transferring provider’s servicing FI/MAC to have the claim adjusted and use an appropriate patient status
code to indicate a transfer.
T-3 Question: Will Medicare cover ambulance transportation (under Part B) for a beneficiary who has been
evacuated from a skilled nursing facility due to a declared emergency and who wishes to return to a nursing
facility closer to family members or home after the emergency/disaster is over?
Answer: Part B of the Medicare AFS covers only local medically necessary ambulance transportation to and
from the nearest appropriate SNF facility, as long as the beneficiary is not a SNF resident in a covered Part A
stay whose transport would be subject to consolidated billing rules. If there are exceptional circumstances
that require transport outside the locality, Medicare can pay for this transport, but only if the destination is
still the nearest SNF with appropriate facilities. In any case, the ambulance transport must be medically
necessary.
T-4 Question: How should a facility bill for a beneficiary who was classified into a Patient Driven Payment Model
(PDPM) category based on a specific service being furnished prior to an emergency when the facility is no
longer able to provide that service as a result of the dislocations associated with the emergency?
Answer: Refer to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, section
2.3 for guidance. Additionally, your servicing Regional Offices, State agency, or MAC can be contacted for
further guidance.
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T-5 Question: Do SNFs have access to Capital PPS Extraordinary Circumstances Exception payments in the same
way that inpatient prospective payment system (IPPS) hospitals do? A SNF, just like an IPPS hospital, could
have capital-related outlier costs associated with treating an expanded population during an emergency.
Answer: No. Section 1886(g)(1)(A) of the Social Security Act which establishes a prospective payment
system for inpatient hospital capital-related costs does not apply to skilled nursing facilities. The SNF PPS
does not currently have a similar mechanism for addressing unusually high capital costs.
T-6 Question: Will physician extenders be allowed to initially certify the need for skilled care in the absence or
unavailability of physicians?
Answer: Section 1814(a)(2) of the Social Security Act in fact already allows a nurse practitioner (NP), a
clinical nurse specialist (CNS), or a physician assistant (PA) to perform not only the subsequent SNF re-
certifications but the initial certification as well, so long as the NP, CNS, or PA is working in collaboration with
a physician and does not have a direct or indirect employment relationship with the SNF. Beyond that, the
already-existing policy that allows for delayed certifications/re-certifications (as set forth in the Internet-Only
Manual at Pub. 100-1, Chapter 4, § 40.5) should be sufficient to address any contingencies related to a
declared emergency.
T-7 Question: A provider has residents who are returning to an evacuated facility. If a resident previously
exhausted the 100-day benefit period, remained at a skilled level of care, (status code 30, no code 22), was
not discharged but was evacuated for a few days and now is back in the facility still requiring skilled care,
does that Medicare beneficiary receive any additional days?
Answer: No. Our intent in issuing a § 1812(f) waiver is to provide additional benefits for a beneficiary who
had exhausted the 100 days of SNF benefits available in the current benefit period and was in the process of
establishing a new benefit period. A new benefit period is established after a period of 60 consecutive days’
elapses during which the beneficiary is not receiving skilled care in a SNF or inpatient hospital care. In the
situation described above, because the beneficiary at the time of a disaster or emergency situation is still
receiving skilled care in the SNF after exhausting the 100 days of SNF benefits, he or she would not be in the
process of establishing a new benefit period at that point and, consequently, would not qualify for additional
coverage under the § 1812(f) waiver.
T-8 Question: Can MDS or PDPM classification system requirements used for determining SNF PPS
reimbursement amounts be waived or modified during an emergency situation to allow for increased
payment?
Answer: There is no provision for such modifications in the absence of a waiver under §1135 of the Social
Security Act. (However, for situations in which a §1135 waiver has, in fact, been issued, please refer to the
discussion of this topic appearing in Section K of the “All Hazards” FAQs at: https://www.cms.gov/About-
CMS/Agency-Information/Emergency/Downloads/Provider-Survey-and-Certification-Frequently-Asked-
Questions.pdf)
T-9 Question: If, in an emergency, a patient cannot be handled in the nursing home and must be admitted to
the hospital for medically necessary treatment, must this care be provided in the emergency department to
qualify for reimbursement?
Answer: There are no requirements that residents of nursing homes must be admitted to the hospital.
Rather, nursing homes “must provide services to attain or maintain the highest practicable physical, mental,
and psychosocial well-being of each resident.” As the requirement is already flexible, there may be no need to
“relax” or institute an alternative rule.
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T-10 Question: If a Medicare beneficiary is transported by ambulance to a local skilled nursing facility (SNF)
because the ambulance was unable to transport the beneficiary to a hospital located in another community
because of factors such as weather, would Medicare payment be available under either of the following two
scenarios?
1. The ambulance service would use space in the SNF that was not used by patients and would
provide the care for the patient under the direction of the ambulance EMS medical director.
2. The staff from the SNF would help provide care for the patients, freeing the ambulance
service staff to take other calls.
Answer: These scenarios implicate both payment policy and conditions of participation and the
permissibility of either scenario may depend on whether a waiver under § 1135 of the Social Security Act
has been granted to the SNF in question. First, in the absence of an 1135 waiver, if the patient needs a
hospital level of care and not a SNF level of care, the SNF cannot be considered a hospital alternative care
site. Therefore, the ambulance transport of the patient to the SNF would not be payable under Medicare
because the SNF would not be the nearest appropriate facility that is capable of furnishing the required
level and type of care for the beneficiary’s illness or injury (see 42 CFR § 410.40(f) for destination
requirements under Medicare AFS. In addition, because the SNF cannot be considered a hospital
alternative care site for furnishing a hospital level of care, no Medicare payment would be available for any
services furnished to the patient while a resident of the SNF.
Even if 1135 waivers were generally available for a particular emergency, because SNFs are not equipped
to provide a hospital level of care, and because neither of the described scenarios entail a hospital
working with a SNF to create an alternate hospital care site at the SNF, with the hospital providing
additional staffing, CMS would likely have strong reservations about approving such a waiver request,
regardless of whether or not the ambulance service would be providing personnel to monitor the
patient(s) at the SNF. However, CMS would review the particular circumstances of the actual situation to
make a determination under an 1135 waiver as to what practices would be permitted along w ith whether
Medicare could pay for any covered services and under which benefit the services would be paid.
T-11 Question: If an individual is unable to go home from a skilled nursing facility (SNF) after the 100 days is over
due to an emergency, will Medicare pay after the 100 days that ended during the emergency period? If so,
what type of minimum data set (MDS) needs to be done and how would the SNF bill Medicare?
Answer: It should be noted that the only payment provisions that can be waived under §1812(f) relate to the
SNF benefit’s qualifying hospital stay requirement, and to the renewal of exhausted SNF benefits for a
beneficiary who was in the process of ending a benefit period at the time of the disaster. All other SNF
coverage and payment requirements, including those relating to the required SNF level of care, remain in
effect in situations where a SNF resident is unable to be discharged to his or her own home due to the
disaster. Accordingly, the difficulty in securing a safe post-discharge environment in this situation cannot, in
itself, serve as a basis for continued Part A coverage of the SNF stay. While Medicare coverage would remain
available for certain individual medical and other health services under Part B, Medicare cannot pay under
Part A for the continued SNF stay itself if the resident no longer requires an SNF level of care at that point or
if the resident’s available benefit days are exhausted during the emergency period. Nevertheless, as noted in
the Federal Emergency Management Agency (FEMA) website at www.fema.gov/ contains information on
special disaster assistance, including the availability of emergency shelters for those who are unable to
remain in or return to their homes due to a disaster.
T-12 Question: Is there any guidance concerning skilled nursing facility (SNF) consolidated billing during an
emergency? For instance, if a patient was scheduled to receive a computed tomography (CT) scan in a
hospital, but due to emergency circumstances, the patient was re-routed to a free-standing imaging
provider), would the SNF be responsible for payment?
Answer: As explained more fully in other Q&As in this section, the only payment provisions that can be
waived under §1812(f) relate to the SNF benefit’s qualifying hospital stay requirement, and to the renewal of
exhausted SNF benefits for a beneficiary who was in the process of ending a benefit period at the time of the
disaster. All other SNF coverage and payment requirements remain in effect, including the consolidated billing
rules under which certain designated high-intensity outpatient services (such as CT scans) are separately
payable under Part B only when furnished in the hospital setting. Thus, the SNF itself would remain
responsible for a CT scan performed in a nonhospital setting, even if the use of the nonhospital setting is
caused by a disaster-related dislocation.
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T-13 Question: If a skilled nursing facility (SNF) is able to keep patients that don't have a place where they may
be safely discharged, but are not in need of skilled services and therefore billed at the non-skilled rate, would
those days count against their 100 days? Or once they are no longer receiving skilled services, would they
start a 60 day break, even though they stay in the facility and are covered by Medicare?
Answer: As explained more fully in other Qs&As in this section, when a SNF resident is unable to be
discharged to his or her own home due to the disaster, the difficulty in securing a safe post-discharge
environment in this situation cannot, in itself, serve as a basis for continued Part A coverage of the SNF stay.
While Medicare coverage would remain available for certain individual medically necessary medical and other
health services under Part B, Medicare cannot pay under Part A for the continued SNF stay itself if the
resident no longer requires an SNF level of care at that point (whether skilled services are provided or not).
Nevertheless, it is worth noting that special disaster assistance from the Federal Emergency Management
Agency (FEMA) can include the availability of emergency shelters for those who are unable to remain in or
return to their homes due to the disaster. Moreover, a 60-day break in skilled care in the SNF does, in fact,
serve to end the beneficiary’s current benefit period, and this would be the case regardless of whether a
disaster-related waiver is in effect.
T-14 Question: A skilled nursing facility (SNF) had a Medicare resident who was at the facility all day, received
rehabilitation services and nursing care, and the family took the patient home to sleep because they had
power and it was warmer there – the SNF was on generator power. The patient slept at the family’s home and
was returned to the SNF the next morning, where he received rehabilitation services, nursing care, etc. Does
the SNF need to code the day as a skipped day, or will CMS take into consideration the extenuating
circumstances and allow it to bill for the services that were provided to him that day?
Answer: If a SNF resident departs (but is not formally discharged) from a facility and does not return by
midnight of the day of departure, the day preceding the midnight on which the resident was absent from the
SNF constitutes a leave of absence (LOA) and that day is not a covered Part A day under the SNF prospective
payment system policy. This is known as the “midnight rule.” We note that while the LOA day is not a covered
Part A day, the therapy given on that day may still be counted in a look-back period that includes that day
pursuant to the policies outlined in Chapter 2 of the MDS 3.0 RAI Manual (available online in the “Downloads”
section at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/MDS30RAIManual.html).
U – Mental Health Counseling
Question Question and Answer
Number
U-1 Question: Will Medicare help pay for counseling to help the beneficiary deal with the mental health issues
associated with the emergency?
Answer: Certain mental health service benefits (including counseling) may be available to Medicare
beneficiaries with Part B coverage. In certain situations, partial hospitalization may also be covered.
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V – Rural Health Clinics / Federally Qualified Health Clinics
Question Question and Answer
Number
V-1 Question: Medicare covered services are provided by Rural Health Clinics (RHCs) and Federally Qualified
Health Centers (FQHCs). May RHCs and FQHCs provide these services to those affected by an emergency?
How does Medicare pay for these services?
Answer: All Medicare Part B beneficiaries, including those affected by an emergency, are eligible to receive
covered services from any Medicare-participating RHC or FQHC, subject to applicable co-pays. The Medicare
portion of the payment to the RHC is based on the clinic’s costs, subject to a limit. FQHCs are paid lesser of
the prospective payment system (PPS) rate or charges.
Under law, Medicare-covered RHC and FQHC services include:
• services by physicians, nurse practitioners, physician assistants, certified nurse midwife, clinical
psychologists, and clinical social workers;
• services and supplies incident to the services of these professionals;
• certain visiting nurse (VN) services to the homebound;
• COVID-19, pneumococcal and influenza vaccines and their administration, and Hepatitis B vaccines and
their administration for high-and intermediate-risk beneficiaries; and
• certain other preventive primary services.
Certain are management and virtual communication services
W – Fee-for-Service Administration
Question Question and Answer
Number
W-1 Question: There does not appear to be any contingency to deal with a situation in which a Medicare
Administrative Contractor (MAC) is severely impacted by an emergency/disaster and unable to be responsive.
Would the workload of an impacted FI/MAC be transferred to other FIs/MACs?
Answer: CMS requires that every Medicare contractor have a continuity of operations plan (COOP) to ensure
that operations are not materially disrupted so that providers and beneficiaries continue to be served. CMS
reviews and approves such plans to ensure that our customers will be adequately served in the event of an
emergency/disaster. CMS also has an Agency-wide COOP which, among other things, would address the
situation where a particular contractor was wholly or partially unable to maintain operations. For security
reasons, the specifics of such COOPs are not made public.
X – Financial Management Policies
Question Question and Answer
Number
X-1 Question: Are accelerated or advance payments available for providers whose practices and/or businesses
were severely affected by an emergency/disaster?
Answer: For providers who are still rendering some services or who are taking steps to be able to render
services again, accelerated or advance payments may be available. Providers in this position should contact
their MAC for details.
X-2 Question: What is CMS’ guideline regarding initiating electronic funds transfer (EFT) for providers affected
by an emergency/disaster who had previously received paper payment (check)?
Answer: All providers are required to receive Medicare payments via EFT. See § 424.510(e). The provider
must complete the CMS-588 EFT Authorization Agreement and supply all required information, i.e., routing
and account numbers, voided check or bank letter.
X-3 Question: If a provider has Medicare debt that it is repaying through the offset of current Medicare
payments or an extended repayment schedule (ERS) and the provider’s or supplier’s business was severely
affected by the emergency/disaster, can the repayment time be deferred and/or extended?
Answer: No. CMS is not permitted to defer or extend payments due under an extended repayment schedule.
Providers and suppliers experiencing financial hardship are encouraged to contact their MAC if they’re
experiencing a temporary disruption in claims payments or billing. ERS schedules may be reviewed to
restructure payments, so long as the payment schedule does not extend past the maximum of 60 months of
payments.
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Question Question and Answer
Number
X-4 Question: If providers choose to waive Medicare deductible or coinsurance amounts for victims of the
emergency/disaster, may the providers claim these waived amounts on the cost report as bad debt? If so,
what documentation will be required in order to satisfy auditors?
Answer: Providers can waive the coinsurance and deductible amounts and claim bad debt for Medicare
patients that they determine to be indigent as provided in 42 CFR § 413.89 and the Provider Reimbursement
Manual Part 1, Chapter 3, § 312. The Provider Reimbursement Manual Part 1, Chapter 3, § 312(B) indicates
that the “provider should take into account any extenuating circumstances that would affect the
determination of the patient’s indigence”.
X-5 Question: In situations in the past in which accelerated or advance payment have been requested, the
request has gone through a very convoluted and stringent process moving from the RO and often to CMS
central. We would hope that in a catastrophic disaster that involves severe disruption in the health care and
financial system infrastructure, that CMS central would communicate clearly to its regions and contractors the
nature of the requirements for accelerated/advance payment are and encourage flexibility in reviewing
requests, especially related to solvency reviews.
Answer: It is CMS’ intent to provide expeditious customer service on accelerated or advance payments.
However, as with most situations requiring payment, there is a concern that a provider will remain viable, or
quickly regain viability, in order to repay the accelerated/advanced payment. Such payments are dependent
on future billings; viability is an important factor and MACs and Regional Offices must ensure that the
payments can be repaid through future billings.
X-6 Question: Will CMS charge interest in a catastrophic disaster in which the financial difficulties are out of the
provider’s control?
Answer: CMS cannot waive interest on debts arising from a Medicare overpayment or debt under separate
authorities.
X-7 Question: CMS policy for expedited/advance payments is very restrictive. Does CMS have the authority to
loosen these rules? If not, would CMS support legislation that would provide additional flexibility to provide
for expedited/advance payment in specific disaster circumstances (e.g., to provide advances on payments to
facilities experiencing a temporary decline in patient population due to disaster so as to allow the facility to
get back up and running)?
Answer: Policy and procedures on advance and accelerated payments are tied to the expectation that claims
or bills are forthcoming; the delay is temporary and accelerated and advance payments are simply that--
“advanced” funds with the expectation that bills will be used to offset the advance. Medicare’s mission is to
reimburse for covered Medicare services; therefore, Medicare billings are critical to its mission. There are
other agencies responsible for relief and rebuilding programs in the wake of disasters or emergencies.
X-8 Question: Do Medicare Administrative Contractors (MACs) have the authority to approve an extension of the
deadline to submit a credit balance report for providers in an area affected by an emergency?
Answer: Contractors have the authority to approve an extension of the deadline to submit a credit balance
report for providers in an area affected by an emergency or disaster. Extensions should be approved for no
longer than 90 days or 1 quarter.
X-9 Question: When should contractors send CMS reports on approvals and denials of provider requests for cost
report credit balance report extensions in areas affected by an emergency or disaster?
Answer: Contractors should submit Emergency reports monthly by the 5th of the following month until
notice to cease doing so is issued.
X-10 Question: Should contractors suspend cost report audits of providers in an area affected by the emergency?
Answer: Contractors shall evaluate on a case-by-case basis if they should continue cost report desk review
and audit activities for providers in areas affected by the emergency.
X-11 Question: When should contractors resume audit activities in areas affected by an emergency?
Answer: Contractors should evaluate on a case-by-case basis when they should resume audit activities in
the affected areas.
X-12 Question: Are there any changes to accelerated/advance reporting in the event of an emergency?
Answer: Yes. Contractors shall add two new fields to their reporting data to reflect the beginning date of
withholding and the outstanding balance.
X-13 Question: Do A/B MACs have the authority to approve accelerated payments in the event of an emergency?
Answer: A/B MACs are given the authority to approve two (2) accelerated payments per provider. Once a
provider makes a request for a third accelerated payment, A/B MACs shall make a recommendation to the
CMS RO and the CMS RO will determine if the accelerated payment is to be approved.
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Question Question and Answer
Number
X-14 Question: Are there any providers who may not receive accelerated payments in the event of an
emergency?
Answer: Providers who are in a bankruptcy situation, who have an active fraud investigation, or who have
not submitted claims within the last 180 days should not have an accelerated payment approved. If the A/B
MAC believes an accelerated payment should be approved in these situations, the A/B MAC shall forward the
case to the CMS’ RO and copy the A/B MAC PO.
Providers who have existing Medicare debts may receive an accelerated payment. Funds from an accelerated
payment should not be used to offset any existing debt the provider currently owes Medicare.
X-15 Question: Are there any physicians or suppliers who may not receive advance payments in the event of an
emergency?
Answer: Physicians/suppliers who are in a bankruptcy situation, who have an active fraud investigation or
who have not submitted claims within the last 180 days should not have an advance payment approved. If
the A/B MAC or DME MAC believes an advance payment should be approved in these situations, the A/B MAC
or DME MAC shall forward the case to the CMS RO or PO.
Physicians/suppliers who have existing delinquent Medicare debts should not receive an advance payment.
Again, if the A/B MAC or DME MAC believes an advance payment should be approved in these situations, the
A/B MAC or DME MAC shall forward the case to the CMS RO and copy the PO.
X-16 Question: In the event of an emergency, would CMS consider making advance payments to hospitals that
cancel elective cases, and other paying procedures that generate money for hospitals, in order to respond to
the influx of medical cases during an emergency, that may not be paying Medicare patients, nor allow for
sustainable margins.
Answer: No, it is not a Medicare option to grant this request. Payment in such cases, if any, would be made
by, and at the discretion of, the Federal Emergency Management Agency (FEMA) and providers seeking such
payments should be referred to FEMA.
X-17 Question: What guidelines will contractors follow related to PIP and pass-through payments in the event of
an emergency?
Answer: Contractors shall work with affected providers (in specified geographic areas) to ensure appropriate
cash flow. The following guidelines should be used in making determinations of appropriate PIP or interim
pass–through payments:
Follow normal operating procedures (i.e., 42 CFR § 413.64(h)(7) and 42 CFR § 413.64(c)(4)), in the
recalculation of PIP and interim pass-through payments. When necessary, suspend or adjust PIP and interim
pass-through payments to any facility that is not operational or has significantly changed its operations. Also,
if any facility changes operations in the future, re-compute PIP and/or interim pass-through payments timely.
X-18 Question: What guidelines shall contractors follow relating to tentative and final settlements in the event of
an emergency?
Answer: Contractors shall follow the following guidelines on tentative and final settlements for affected
providers (in specified geographic areas):
Issue tentative and final settlements based on normal procedures for providers whose operations were not
impacted by the emergency.
Determine on a case-by-case basis, if tentative and final settlements should be issued for providers in the
affected areas that were impacted by the emergency. Contractors shall issue tentative and final settlements
to providers impacted by the emergency if the settlement results in a payment to the provider. Contractors
may delay issuing tentative and final settlements if circumstances merit a delay.
Where a contractor determines it should delay making a tentative or final settlement to a provider in the
affected area, please notify CMS Central Office of this determination (the POC and timeframes to be specified
at the time of the emergency/disaster). The contractor shall re-assess the provider’s status every 30 days to
determine when it should proceed with the outstanding tentative or final settlement. Contractors shall update
such notice by the 15th of each month with any additions or deletions in delayed settlements.
X-19 Question: May a provider delay its monthly payment of their Extended Repayment Schedule (ERS)?
Answer: No, payments may not be deferred; however, the provider should contact their Medicare contractor
for more information. Providers and suppliers experiencing financial hardship may request payments be
restructured, if eligible.
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Question Question and Answer
Number
X-20 Question: Are requests for accelerated and advance payments retroactive to the effective date of the
Secretary’s issuance of the waiver?
Answer: Yes.
X-21 Question: Will the recovery process for providers receiving an accelerated or advance payment be different
due to a Public Health Emergency?
Answer: The manual provides 90 days for recoupment of the accelerated or advance payment after the date
of issuance of an accelerated or advance payment, or if the payment is issued due to claims processing
disruptions, the time frame is 90 days from the time the MAC begins processing the provider/ supplier's
payments. Please see Chapter 3, section 150 of the Medicare Financial Management Manual.
X-22 Question: I am an attorney representing a Medicare beneficiary in a liability insurance (or no-fault insurance
or workers’ compensation) matter. My client’s claim has settled. He/she has incurred additional expenses due
to a public health emergency. How can I expedite CMS’ determination regarding whether or not Medicare has
a recovery claim against my client’s settlement due to the Medicare Secondary Payer rules?
Answer: If you have a client residing in a State where a public health emergency has been declared, you
may telephone the Benefits Coordination and Recovery Center (BCRC) to request expedited conditional
payment information and/or an expedited demand letter provided the case has settled. The demand triggers
the process to quickly resolve Medicare claims and releases funds to the beneficiary. The contact number is 1-
855-798-2627. Please note that this assumes that you have first notified them of your pending case so that
the matter has been established in CMS’ systems as a potential recovery case. The BCRC has no way to
expedite further action until a potential recovery case has been established in CMS’ systems.
Y – Medicare FFS Appeals
Question Question and Answer
Number
Y-1 Question 1: Can beneficiaries in affected areas receive an extension to file an appeal?
Answer: Yes, for good cause, affected beneficiaries may receive extensions to file appeal requests.
Beneficiaries in affected areas should indicate they were impacted by an emergency or disaster in their
appeal requests.
Y-2 Question 2: What happens if the Medicare contractor needs additional documentation to support a pending
appeal, but the provider/supplier is in an affected area?
Answer: Medicare contractors will work with the provider/supplier to obtain the necessary documentation.
Y-3 Question 3: What if providers/suppliers in affected areas are unable to file appeals within 120 days from the
date of receipt of the Remittance Advice (RA) that lists the initial determination?
Answer: For good cause, Medicare contractors may accept late appeal requests from providers/suppliers.
Providers/suppliers in affected areas should indicate they were impacted by an emergency or disaster in their
appeal requests.
Y-4 Question 4: What if providers/suppliers in affected areas are unable to receive RAs for an extended period of
time, which can impact their ability to file timely appeals?
Answer: The time to file an appeal does not begin until a provider receives the RA. Receipt is presumed to be
five days from the date of issuance of the RA unless there is evidence to the contrary. If an emergency or
disaster disrupts the receipt of RAs, the provider/supplier should explain the circumstances and document the
actual date of receipt in its appeal request. Moreover, for good cause, Medicare contractors may accept late
appeal requests from providers/suppliers. Providers/suppliers in affected areas should indicate they were
impacted by an emergency or disaster in their appeal requests.
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