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MIR-2007 04AB, April 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Services Not Provided Within United States
Provider Types Affected
Physicians, suppliers, and providers who submit claims to Medicare carriers, fiscal intermediaries (FI) and A/B Medicare Administrative Contractors (A/B MAC)
Key Points
CR5427 clarifies that payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States.
Take Note: Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.
Background
This article and related Change Request (CR) 5427 outlines the limited items and services that are reimbursable by Medicare outside the United States according to Section 1862(a)(4) of the Social Security Act.
The law specifies the following exceptions to the “foreign” exclusion:
- Inpatient hospital services for treatment of an emergency in a foreign hospital that is closer to, or more accessible from, the place the emergency arose than the nearest U.S. hospital that is adequately equipped and available to deal with the emergency, provided either of the following conditions exist:
- emergency arose within the U.S.; or
- emergency arose in Canada while the individual was traveling, by the most direct route and without unreasonable delay between Alaska and another state
- Inpatient hospital services at a foreign hospital that is closer to, or more accessible from, the individual’s residence within the U.S. than the nearest U.S. hospital that is adequately equipped and available to treat the individual’s condition, whether or not an emergency exists.
- Physician and ambulance services in connection with, and during, a foreign inpatient hospital stay that is covered in accordance with either of the above.
Additional Information
CR5427 is the official instruction issued to your Medicare carrier, FI or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R66BP.pdf  on the Centers for Medicare & Medicaid Services (CMS) Web site.
If you have questions, please contact your Medicare carrier, FI or A/B MAC, at their toll-free number which may be found at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS Web site.
NOTE: The previously published CR3781 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3781.pdf also provides information and instructions about services not provided within the United States by defining “United States” for the purposes of the Social Security Act (Section 1814 (f) along with the parameters of this Medicare rule.
Flu Shot Reminder - It’s Not Too Late to Give and Get the Flu Shot!
The peak of flu season typically occurs between late December and March; however, flu season can last until May. Protect yourself, your patients, and your family and friends by getting and giving the flu shot. Each office visit presents an opportunity for you to talk with your patients about the importance of getting an annual flu shot and a lifetime pneumococcal vaccination. Remember - influenza and pneumococcal vaccination and their administration are covered Part B benefits. Note that influenza and pneumococcal vaccines are NOT Part D covered drugs. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5427
Pub. 100-2, Transmittal# R66BP, CR# 5427
Related CR Release Date: February 23, 2007
Effective Date: November 13, 2006
Implementation Date: April 2, 2007
Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/  on the CMS Web site.
| CPT five-digit codes, descriptions, and other data only are copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS clauses apply. |
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