When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Centers for Medicare & Medicaid Services (CMS). Federal Register. Part II: Department of Health and Human Services CMS. Clarifying policies related to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions. [CMS Web site]. 03/30/2007. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/Transplantfinal.pdf. Accessed September 1, 2015.
Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections: 20.2 – Definitions of Emergency and Urgently Needed Services. [CMS Web site]. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf. Accessed September 1, 2015.
Centers for Medicare & Medicaid Services (CMS). Medlearn Matters (MM).MM #5427: Services Not Provided Within United States.[CMS Web site]. 8/24/2012. Available at:
https://www.cms.gov/MLNMattersArticles/downloads/MM3781.pdf . Accessed September 1, 2015.
450 General classification
451 EMTALA* Emergency Medical Screening Services
452 ER Beyond EMTALA* Screening
456 Urgent Care
459 Other Emergency Room
* EMTALA represents the Federal Emergency Medical Treatment and Active Labor Act
681 Level I
682 Level II
683 Level III
684 Level IV
689 Other Trauma Response
981 Emergency Room