INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A400 |
§489.20 Basic Section 1866
commitments relevant to Section 1867 responsibilities. The
provider agrees-- (l)
In the case of a hospital as defined in §489.24(b), to comply with §489.24. |
INTERPRETIVE
GUIDELINES: §489.20(l) §489.20(l) requires the provider to comply with §489.24. However §1866(a)(1)(I)(i) of the Act requires providers to adopt and enforce a policy to ensure compliance with the requirements of §1867 (§489.24). Non-compliance is a violation of the provider's agreement with the Health Care Financing Administration (HCFA). Therefore, if the provider violates §489.24, cite a corresponding violation of §489.20(l); but if the provider does not adopt and enforce procedures and policies to ensure compliance with §489.24, cite a violation of §1866(a)(1)(I)(i). o Check the bylaws/rules and regulations
of the medical staff to determine if they reflect the requirements of §489.24
and the related requirements at §489.20. o Review the emergency department
policies and procedure manuals for procedures related to the requirements of
§489.24 and the related requirements at §489.20. The
term "hospital" is defined in §489.24(b) as including a rural
primary care hospital as defined in §1861(mm)(1) of the Act. |
A401 |
(m)
In the case of a hospital as defined in §489.24(b), to report to HCFA or the
State survey agency any time it has reason to believe it may have received an
individual who has been transferred in an unstable emergency medical
condition from another hospital in violation of the requirements of
§489.24(d). |
INTERPRETIVE
GUIDELINES: §489.20(m) Look
for evidence that the receiving (recipient) hospital knew or suspected the
individual had been to a hospital prior to the receiving (recipient) hospital
and had not been transferred in accordance with §489.24(d). (Evidence may be obtained in the medical
record or through interviews with the patient, family members or staff.) However, termination of the receiving
(recipient) hospital should be suspended pending confirmation of the
suspected offense. Review
the emergency department log and medical records of patients received as
transfers. Look for evidence that: o The hospital had agreed in advance to
accept the transfers; o The hospital had received appropriate
medical records; o All transfers had been effected through
qualified personnel, transportation equipment and medically appropriate life
support measures; and o The hospital had available space and
qualified personnel to treat the patients. |
Rev. 2 05-98 V-13
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A402 |
(q)
In the case of a hospital as defined in §489.24(b)-- (1)
To post conspicuously in any emergency department or in a place or places
likely to be noticed by all individuals entering the emergency department, as
well as those individuals waiting for examination and treatment in areas
other than traditional emergency departments (that is, entrance, admitting
area, waiting room, treatment area) a sign (in a form specified by the
Secretary) specifying the rights of individuals under section 1867 of the Act
with respect to examination and treatment for emergency medical conditions
and women in labor; and (2)
To post conspicuously (in a form specified by the Secretary) information
indicating whether or not the hospital or rural primary care hospital
participates in the Medicaid program under a State plan approved under Title
XIX; |
INTERPRETIVE
GUIDELINES: §489.20(q) At
a minimum: o The sign(s) must specify the rights of
individuals with emergency conditions and women in labor who come to the
emergency department for health care services; o It must indicate whether the facility
participates in the Medicaid program; o The wording of the sign(s) must be
clear and in simple terms and language that are understandable by
the population served by the hospital; and o The sign(s) must be posted in a place
or places likely to be noticed by all individuals entering the emergency
department, as well as those individuals waiting for examination and
treatment (e.g., entrance, admitting area, waiting room, treatment area). |
A403 |
(r)
In the case of a hospital as defined in §489.24(b) (including both the
transferring and receiving hospitals), to maintain-- (1)
Medical and other records related to individuals transferred to or from the
hospital for a period of 5 years from the date of the transfer; |
INTERPRETIVE
GUIDELINES: §489.20(r)(1) The
medical records of individuals transferred to or from the hospital must be
retained in their original or legally-reproduced form in hard copy,
microfilm, microfiche, optical disks, computer disks,
or computer memory . |
Rev. 2 05-98 V-14
INTERPRETIVE GUIDELINES -
RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE TO SURVEYORS |
A404 |
(2) A list of physicians who are on
call for duty after the initial examination to provide further evaluation
and/or treatment necessary to stabilize an individual with an emergency
medical condition; and |
INTERPRETIVE GUIDELINES: §489.20(r)(2) The purpose of the on-call list is to ensure that the emergency department is prospectively aware of which physicians, including specialists and subspecialists, are available to provide treatment necessary to stabilize individuals with emergency medical conditions. If a hospital offers a service to the public, the service should be available through on-call coverage of the emergency department. The medical staff by-laws
or policies and procedures must define the responsibility of on-call
physicians to respond, examine and treat patients with emergency medical conditions. Physicians, including specialists and subspecialists (e.g., neurologists) are not required to be on call
at all times. The hospital must have
policies and procedures to be followed when a particular specialty is not
available or the on-call physician cannot respond because of situations
beyond his or her control. Each hospital has the
discretion to maintain the on-call list in a manner to best meet the needs of
its patients. Physicians are not required to be on
call in their specialty or subspecialty for emergencies whenever they are visiting
their own patients in a hospital. Review the hospital's policy with
respect to response time of the on-call physician. Hospitals are responsible for ensuring that on-call physicians
respond within a reasonable period of time.
Note the time of notification and the response (or transfer) time. If a staff physician is on-call to
provide emergency services or to consult with an emergency room physician
is in the area of his or her
expertise, that physician would be considered to be available at the
hospital. Where a physician is on-call in
an office it is not acceptable to refer emergency cases to their
offices for examination and treatment.
The physician must come to the hospital to examine the patient unless
the physician is a hospital-owned facility on contiguous land or on the
hospital campus.. If a physician demonstrates a pattern
of not arriving at the hospital while on-call, but directs the patient to be
transferred to another hospital where that physician can treat the patient,
this may be a violation. |
A405 |
(3) A central log on each
individual who "comes
to the emergency department," as defined in §489.24(b),
seeking assistance and whether he or she refused treatment, was refused
treatment, or whether he or she was transferred, admitted and treated,
stabilized and transferred, or discharged. |
INTERPRETIVE GUIDELINES: §489.20(r)(3) The purpose of the central log
is to track the care provided to each individual who comes to the hospital
seeking care for an emergency medical condition. Each hospital has the discretion
to maintain the central log in a form that best meets the needs of its
patients. The central log includes,
directly or by reference, patient logs from other areas of the hospital, such
as pediatrics and labor and delivery where a patient might present for
emergency services or receive a medical screening examination instead of in
the emergency department. These
additional logs must be available in a timely manner for surveyor review. Review the emergency department log
covering at least a six month period that contains information on all
patients coming to the emergency department and check for completeness, gaps
in entries or missing information. |
Rev. 2 05-98 V-15
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A405
(Cont.) A406 |
§489.24 Special responsibilities of Medicare
hospitals in emergency cases. (a)
General. In the case of a
hospital that has an emergency department, |
Select
a sample of records from the past six months from the log for review to
determine compliance with the §489.24 requirements, according to the sample
size methodology in Task 2. Select
an older sample if the case to be investigated occurred longer than six
months ago, or if you are concerned about a possible
long-term pattern of dumping. THE PROVISIONS OF THIS
REGULATION APPLY TO ALL HOSPITALS THAT PARTICIPATE IN MEDICARE AND PROVIDE
EMERGENCY SERVICES Hospitals
providing emergency services are required to provide for an
appropriate medical screening examination;
provide necessary stabilizing treatment for emergency medical
conditions and labor; provide for an
appropriate transfer of the patient if the hospital does not have
the capability or capacity to provide the treatment necessary to stabilize
the emergency medical condition; , not delay examination and/or treatment in
order to inquire about the patient's insurance or
payment status; accept appropriate
transfers of patients with emergency medical
conditions if the hospital has the specialized capabilities not
available at the transferring hospital and has the capacity to treat those
individuals; if the patient refuses examination, treatment, or transfer
to obtain or attempt to obtain written and informed refusal of examination,
treatment or appropriate transfer; and not take adverse action against a
physician or qualified medical personnel who refuses to transfer a
patient with an emergency medical condition, or against an employee who
reports a violation of these requirements. INTERPRETIVE
GUIDELINES: §489.24(a) A
"hospital with an emergency department" is defined in paragraph (b)
of this section as one which offers services for emergency medical conditions
within its capability to do so. Lack of an established emergency
department is not an indication that emergency services are not
provided. If a hospital offers
emergency services for medical, psychiatric or substance abuse emergency
conditions, it is required, within its capability and capacity, to comply
with all the anti-dumping statutory requirements. If
a psychiatric hospital offers services for medical, psychiatric, or substance
abuse emergency conditions, it is obligated to comply with all of the
anti-dumping requirements of §§489.20 and 489.24. Most
psychiatric hospitals are accredited by the Joint Commission and have an
emergency department which provides reasonable care in determining whether an
emergency exists, renders life saving first aid, and makes appropriate
referrals to the nearest organizations that are capable of providing needed
services. The emergency department
must have a mechanism for providing physician coverage at all times. |
Rev. 2 05-98 V-16
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A406 (Cont.) |
If
any individual (whether or not eligible for Medicare benefits and regardless
of ability to pay) comes by him or herself or with another person to the
emergency department and a request is made on the individual's behalf for
examination or treatment of a medical condition by qualified medical
personnel (as determined by the hospital in its rules and regulations), the
hospital must provide for an appropriate MEDICAL SCREENING EXAMINATION within
the capability of the hospital's emergency department, including ancillary
services routinely available to the emergency department |
Emergency
services need not be provided in a location specifically identified as an
emergency room or an emergency department.
If an individual arrives at a hospital and is not technically in the
emergency department, but is on the premises (including the parking lot,
sidewalk and driveway) of the hospital and requests emergency care, he or she
is entitled to a medical screening examination. For example, it may be the hospital's
policy to direct all pregnant women to the labor and delivery area of the
hospital. Hospitals may use areas to
deliver emergency services which are also used for other inpatient or
outpatient services. Medical
screening examinations or stabilization may require ancillary services
available only in areas or facilities of the hospital outside of the
emergency department. As long as the
patient is directed to a hospital-owned facility which is contiguous (i.e.,
any area within the hospital or a hospital-owned facility on land that
touches land where a hospital's emergency department sits) or is
part of the hospital "campus"
and is owned by the hospital, and is operating under the hospital's provider
number, the hospital is complying with §1867. Physicians' offices may be
defined as such a facility, provided they are located in a hospital-owned
building which is contiguous or located in a hospital-owned building which is"on
campus."
For example, a patient who presents to the emergency department could be sent
to whatever hospital-owned contiguous or on-campus facility that the hospital
deemed appropriate to conduct or complete the medical screening examination
as long as (1)all persons with the same medical condition are moved to this
location, regardless of their ability to pay for the treatment; (2)there is a
bona fide medical reason to move the patient; and (3) qualified medical
personnel accompany the patient. If
the patient was initially screened in a facility outside of the emergency
department, the patient could be moved to another hospital-owned contiguous
or hospital-owned on-campus facility to receive additional screening or for
stabilization without such movement being regarded as a transfer, as long as
(1) all persons with the same medical condition are moved in such
circumstances, regardless of their ability to pay for treatment; (2) there is
a bona fide medical reason to move the patient; and (3) qualified medical
personnel accompany the patient. If
a patient comes to any contiguous or on-campus facility of a hospital that
has one or more hospital-owned non-contiguous or off-campus facilities (such
as an urgent care center or satellite clinic), the medical screening
examination must be performed within the contiguous or on-campus facilities
of the hospital. The hospital should
not move the patient to a non-contiguous or off-campus facility for the
medical screening examination. |
Rev.
2 05-98 V-17
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A406 (
Cont.) |
|
If
a patient comes to a hospital-owned facility which is non-contiguous or
off-campus and operates under the hospital's Medicare provider
number, §1867 applies to that facility. The facility must therefore screen and stabilize the patient
to the best of its ability or execute an appropriate transfer according to §1867
guidelines if necessary. If
an individual is not on hospital
property, this regulation is not applicable. Hospital
property includes ambulances owned and operated by the hospital, even if the
ambulance is not on hospital grounds.
An individual in a nonhospital-owned ambulance which is on hospital
property is considered to have come to the hospital's emergency
department. An individual in a
nonhospital-owned ambulance not on "Hospital A's" property is not
considered to have come to "Hospital A's" emergency department when
the ambulance personnel contact "Hospital A" by telephone or telemetry
communications. A hospital
may deny access to patients when it is in "diversionary" status
because it does not have the staff or facilities to accept any additional
emergency patients at that time.
However, if the ambulance disregards the hospital's instructions and
brings the individual on to hospital grounds, the individual has come to
the hospital and the hospital cannot deny the individual access to
hospital services. Should
a hospital which is not in diversionary status fail to accept a
telephone or radio request for transfer or admission, the refusal could
represent a violation of other Federal or State requirements (e.g.,
Hill-Burton). If you suspect a
violation of related laws, refer the case to the responsible agency for
investigation. |
Rev. 2 05-98 V-18
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITAL IN EMERGENCY
CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A406 (Cont) |
|
Hospitals
are obligated to screen patients to determine if an emergency medical
condition exists. It is not
appropriate to merely "log
in"
a patient and not provide a medical screening examination. Medicare
participating hospitals that provide emergency services must provide a
medical screening examination to any individual regardless of diagnosis
(e.g., labor, AIDS), financial status (e.g., uninsured Medicaid), race,
color, national origin (e.g., Hispanic or Native American surnames),
handicap, etc. Individuals
coming to the emergency department must be provided a medical screening
examination beyond initial triaging.
Triage is not equivalent to a medical screening examination. Triage merely determines the "order"
in which patients will be seen, not the presence or absence of an emergency
medical condition. A
hospital, regardless of size or patient mix, must provide screening and
stabilizing treatment within the scope of its abilities, as needed, to the
individuals with emergency medical conditions who come to the hospital for
examination and treatment. The
medical screening examination must be the same medical screening examination
that the hospital would perform on any individual coming to the hospital's
emergency department with those signs and symptoms, regardless of the
individual's ability to pay for medical care. If the medical screening examination is appropriate and does
not reveal an emergency medical condition, the hospital has no further
obligations under 42 CFR 489.24. Regardless
of a positive or negative patient outcome, a hospital would be in violation
of the anti-dumping statute if it fails to meet any of the medical screening
requirements under 42 CFR 489.24. A medical screening examination is the
process required to reach with reasonable clinical confidence, the point at
which it can be determined whether a medical emergency does or does not
exist. If a hospital applies in a
nondiscriminatory manner (i.e., a different level of care must not exist
based on payment status, race, national origin) a screening process that is
reasonably calculated to determine whether an emergency medical condition
exists, it has met its obligations under the Emergency Medical Treatment and
Labor Act (EMTALA). Depending
on the patient's presenting symptoms, the medical screening examination
represents a spectrum ranging from a simple process involving only a brief
history and physical examination to a complex process that also involves
performing ancillary studies and procedures such as (but not limited to)
lumbar punctures, clinical laboratory tests, CT scans, and/or diagnostic
tests and procedures. A
medical screening examination is not an isolated event. It is an ongoing process. The record must reflect continued
monitoring according to the patient's needs and must continue until he/she is
stabilized or appropriately transferred.
There should be evidence of this evaluation prior to discharge or
transfer. |
Rev.
2 05-98 V-19
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A406 (Cont.) |
|
The
clinical outcome of an individual's condition is not a proper basis for
determing whether an appropriate screening was provided or whether a person
transferred was stabilized. However,
it may be a "red flag" indicating a more thorough investigation is
needed. Do not make decisions base on
clinical information that was not available at the time of stabilization or
transfer. If
a misdiagnosis occurred, but the hospital utilized all of its resources, a
violation of the screening requirement did not occur. A
hospital may not refuse to screen an enrollee of a managed care plan because
the plan refuses to authorize treatment or to pay for such screening and
treatment. Likewise, the managed care
plan cannot refuse to screen and treat or appropriately transfer individuals
not enrolled in the plan who come to a plan hospital that participates in the
Medicare program. It
is not appropriate for a hospital to request or a health plan to require
prior authorization before the patient has received a medical screening exam
to determine the presence or absence of an emergency medical condition or
until an existing emergency medical condition has been stabilized. Once an emergency medical condition has
been determined not to exist or the emergency medical condition has been
stabilized, §1867 of the Act no longer applies and prior
authorization for further services can be sought. (NOTE:
Background issue on Payment: Once
a patient has presented to the hospital seeking emergency care, the
determination of whether an emergency medical condition exists is made by the
examining physician(s) or other qualified medical person actually caring for
the patient at the treating facility, not the managed care plan. Beneficiaries have a right to emergency
services if they have symptoms of sufficient severity (which may include
severe pain) and sudden onset, and they are acting reasonably, given their
knowledge, experiences, and state of mind.) |
Rev. 2 05-98 V-20
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY
CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A406
(Cont.) |
|
Prearranged
community or State plans which identify certain hospitals that will care for
selected individuals (e.g., Medicaid patients, psychiatric patients, pregnant
women; (see tag A407)) do not relieve other hospitals of the obligation to
comply with the screening and treatment requirements of §489.24 before
appropriately transferring the individual. If
a screening examination reveals an emergency medical condition and the
individual is told to wait for treatment, but the individual leaves the
hospital, the hospital did not "dump"
the patient unless: o The individual left the emergency department based on a "suggestion"
by the hospital, and/or o The individual's condition was emergent, but
the hospital was operating beyond its capacity and did not attempt to
transfer the individual to another facility. Hospital
resources and staff available to inpatients at the hospital for emergency
services must likewise be available to individuals coming to the hospital for
examination and treatment of emergency medical conditions because these
resources are within the capability of the hospital. For example, a woman in labor who presents
at a hospital providing obstetrical services must be treated with the
resources available, whether or not the hospital normally provides unassigned
emergency obstetrical services. If
a hospital chooses to meet its responsibility to provide adequate medical
personnel to meet its anticipated emergency needs by using on-call physicians
either to staff or to augment its emergency department, then the capability
of its emergency department includes the services of its on-call physicians. |
Rev.
2 05-98 V-21
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY
CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A406
(Cont.) A406 (Cont.)
|
to
determine whether or not an emergency medical condition exists. The
examinations must be conducted by individuals determined qualified by
hospital bylaws or rules and regulations and who meet the requirements of
§482.55 concerning emergency services personnel and direction. |
"Emergency
medical condition" means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain, psychiatric
disturbances, and/or symptoms of substance abuse) such that the absence of
immediate medical attention could reasonably be expected to result in: o Placing the health of the individual
(or, with respect to a pregnant woman, the health of a woman or her unborn child)
in serious jeopardy; o Serious impairment to any bodily
functions; o Serious dysfunction of any bodily organ
or part; or o With respect to a pregnant woman who is
having contractions: -- That there is inadequate time to effect
a safe transfer to another hospital before delivery, or -- That the transfer may pose a threat to
the health or safety of the woman or the unborn child. Psychiatric
hospitals that provide emergency services are obligated under these
regulations to respond within the limits of their capabilities. Some
intoxicated individuals may meet the definition of "emergency medical
condition" because the absence of medical treatment may place their
health in serious jeopardy, result in serious impairment of bodily functions,
or serious dysfunction of a bodily organ.
Further, it is not unusual for intoxicated individuals to have
unrecognized trauma. Likewise,
an individual expressing suicidal or homicidal thoughts or
gestures, if determined dangerous to self or others, would be considered to
have an emergency medical condition. This
delegation should be set forth in a document approved by the governing body
of the hospital. If the rules and
regulations of the hospital are approved by the board of trustees or other
governing body, those personnel qualified to perform these examinations may
be set forth in the rules and regulations, instead of placing this
information in the hospital by-laws.
It is not acceptable for the hospital to allow informal personnel
appointments that could frequently change. |
Rev.
2 05-98
V-22
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
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TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
|
(c)
Necessary stabilizing treatment for emergency medical conditions and labor
-- |
"Labor",
as defined in paragraph (b) of this section, means the process of childbirth
beginning with the latent or early phase of labor and continuing through the
delivery of the placenta. A woman is
in true labor unless a physician or qualified individual certifies that,
after a reasonable time of observation, the woman is in false labor. |
A407 |
(1)
General. If any individual
(whether or not eligible for Medicare benefits) comes to a hospital and the
hospital determines that the individual has an emergency medical condition, |
INTERPRETIVE
GUIDELINES : §489.24(c)(I) A
managed health care plan (e.g., HMO, PPO) cannot deny a hospital permission
to treat its enrollees. It may only
state what it will or will not pay for.
Regardless of whether a hospital will be paid, it is obligated to
provide the services specified in the statute and this regulation. |
|
the
hospital must provide either-- |
|
|
(I)
Within the capabilities of the staff and facilities available at the
hospital, |
Capabilities
of a medical facility means that there is physical space, equipment,
supplies, and services that the hospital provides (e.g., surgery, psychiatry,
obstetrics, intensive care, pediatrics, trauma care). Capabilities
of the staff of a facility means the level of care that the personnel of the
hospital can provide within the training and scope of their professional
licenses. The
capacity to render care is not reflected simply by the number of persons
occupying a specialized unit, the number of staff on duty, or the amount of
equipment on the hospital's premises.
Capacity includes whatever a hospital customarily does to accommodate
patients in excess of its occupancy limits §489.24(b). If a hospital has customarily accommodated
patients in excess of its occupancy limits by whatever means (e.g., moving
patients to other units, calling in additional staff, borrowing equipment
from other facilities) it has, in fact, demonstrated the ability to provide
services to patients in excess of its occupancy limits. The
by-laws, protocols and medical staff appointments approved by the governing
body should require that all individuals are screened and stabilized
within the capability of the hospital and should specify which staff members (by
position) are authorized to perform the treatment. A
hospital may appropriately transfer an individual before the sending hospital
has used and exhausted all of its resources available if the individual
requests the transfer to another hospital for his or her treatment, and
refuses treatment at the sending hospital. (See Tag A409.) If
a community-wide plan exists for certain hospitals to treat certain emergency
medical conditions, then the individual should be screened, stabilized,
or appropriately transferred to the community-plan hospital. |
Rev.
2 05-98 V-23
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY
CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A407 (Cont.) |
for
Further Medical Examination and Treatment as required to stabilize the
medical condition; or |
Compliance
with the medical screening examination and stabilization requirements under §1867
mandate that all patients with similar medical conditions be treated
consistently. In some cases, local,
State, or regionally-approved emergency medical systems (EMS),
point-of-entry, and/or system protocols are in place. Compliance with EMS protocols with respect
to the transport of emergent patients is usally deemed to indicate compliance
with §1867; however a copy of the protocol should be obtained and
reviewed at the time of the survey.
If a hospital complies with other regional authority or State or
locally approved point-of-entry protocols for emergency care (e.g., for
psychiatric emergencies or physicial or sexual abuse) then the hospital is
usually in compliance with §1867of the Act, as long as the
hospital ensures that the patient is stable for transfer. If
the individual seeking care is a member an HMO or CMP, the hospital's
obligation to comply with the requirements of §489.24 is not affected. "To
stabilize," as defined in
paragraph (b) of this section means, with respect to an emergency medical
condition, to either provide such medical treatment of the
condition necessary to assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result from, or occur
during, the transfer of the individual from a facility, or that the woman has
delivered the child and the placenta.
A patient will be deemed stabilized if the treating physician
attending to the patient in the emergency department/hospital has determined,
within reasonable clinical confidence, that the emergency medical condition
has been resolved. For patients whose
emergency medical condition has not been resolved, the determination of
whether they are stable "medically" may occur in one of the
following two circumstances: o For purposes of transferring a patient
from one facility to a second facility "stable for transfer"; and o For purposes of discharging a patient
other than for the purpose of transfer from one facility to another facility
"stable for discharge". For
transfer between facilities: a patient is stable for transfer if the patient
is transferred from one facility to a second facility and the treating physician attending to
the patient has determined, within reasonable clinical confidence, that the
patient is expected to leave the hospital and be received at the second
facility, with no material deterioration in his/her medical condition; and
the treating physician reasonably believes the receiving facility has the
capability to manage the patient's medical condition and any
reasonably foreseeable complication of that condition. If
there is a disagreement between the treating physician and an off-site
physician (e.g., a physician at the receiving facility or the patient's
primary care physician if not physically present at the first
facility)about whether a patient is
stable for transfer, the medical judgment of the treating physician usually
takes precedence over that of the off-site physician. |
Rev.
2 05-98 V-24
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE HOSPITALS IN EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A407 (Cont.) |
for
FURTHER MEDICAL EXAMINATION AND
TREATMENT as required to stabilize the medical condition; or (ii)For
transfer of the individual to another medical facility in accordance with
paragraph (d) of this section. |
If
a physician is not physically present at the time of transfer, then qualified
personnel (as determined by hospital bylaws or other board-approved
documents) in consultation with a physician can determine if a patient is
stable for transfer. The
failure of a receiving facility to provide the care it maintained it could
provide to the patient when the transfer was arranged, should not be
construed to mean the patient's condition worsened as a result of the
transfer. A
patient is considered stable for discharge (vs. for transfer from one
facility to a second facility) when, within reasonable clinical confidence,
it is determined that the patient has reached the point where his/her
continued care, including diagnostic work-up and/or treatment, could be
reasonable performed as an outpatient or later as an inpatient, provided the
patient is given a plan for appropriate follow-up care with the discharge
instructions. For
purposes of transferring a patient from one facility to a second facility, for
psychiatric conditions, the patient is considered to be stable
when he/she is protected and prevented from injuring himself/herself or
others. For purposes of discharging a
patient (other than for the purpose of transfer from one facility to a second
facility), for psychiatric conditions, the patient is considered to be stable
when he/she is no longer considered to be a threat to him/herself or to
others. "Stable
for transfer" or "Stable for discharge" does not require the
final resolution of the emergency medical condition. Hospitals
may not circurnvent the requirements in §489.24 by admitting
individuals with emergency medical conditions to other departments of the
hospital and then discharging them prior to stabilization. These requirements apply to all areas
of the hospital. "Transfer" as defined in
paragraph (b) of this section, means the movement (including the discharge)
of an individual outside a hospital's facilities at the direction of any
person employed by (or affiliated or associated, directly or indirectly,
with) the hospital, but does not include such a movement of an individual who
has been declared dead or leaves the facility without the permission of any
such person. If discharge would
result in the reasonable medical probability of material deterioration of the
patient, the emergency medical condition should not be considered to have
been stabilized. When
a hospital has exhausted all of its capabilities in attempting to remove the
emergency medical condition, it must effect an appropriate transfer of the
individual. (See Tag A409) |
Rev.
2 05-98 V-25
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY
CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A407
(Cont.) |
(2)
Refusal to consent to treatment.
A hospital meets the requirements of paragraph (c)(1)(i) of this
section with respect to an individual if the hospital offers the individual
the further medical examination and treatment described in that paragraph and
informs the individual (or a person acting on the individual's behalf) of the
risks and benefits to the individual of the examination and treatment, but
the individual (or a person acting on the individual's behalf) refuses to
consent to the examination and treatment.
The medical record must contain a description of the examination,
treatment, or both if applicable, that was refused by or on behalf of the
individual. The hospital must take
all reasonable steps to secure the individual's written informed refusal (or
that of a person acting in his or her behalf). The written document should indicate that the person has been
informed of the risks and benefits of the examination or treatment, or both. |
Emergency
medical conditions must be stabilized.
If a woman is in labor, the hospital must deliver the baby or transfer
appropriately. She may not be
transferred unless she, or a legally responsible person acting on her behalf,
requests a transfer or if a physician or other qualified medical personnel,
in consultation with a physician, certifies that the benefits to the
condition of the woman and/or the unborn child outweigh the risks associated
with the transfer. If
the individual's condition requires immediate medical stabilizing treatment
and the hospital is not able to attend to that individual because the
emergency department is operating beyond its capacity, then the hospital
should transfer the individual to a facility that has the capability and
capacity to treat the individual's emergency medical condition, it possible. INTERPRETIVE
GUIDELINES: §489.24(c)(2) The
medical record should reflect that screening, further examination, and/or
treatment was offered by the hospital prior to the individual's refusal. In
the event an individual refuses to consent to further examination or
treatment, the hospital must indicate in writing the risks/benefits of the
examination and/or treatment; the reasons for refusal; a description of the
examination or treatment that was refused; and the steps taken to try to
secure the written, informed refusal if it was not secured. Hospitals
may not attempt to coerce individuals into making judgments against their
best interest by informing them that they will have to pay for their care if
they remain, but that their care will be free or at low cost if they transfer
to another hospital. A
hospital cannot be left without recourse if an individual refuses treatment,
refuses to sign a statement to that effect, and leaves against medical
advice. Hospitals may document such
refusals as they see fit. An
individual may only refuse examination, treatment, or transfer on behalf
of the patient if the patient is incapable of making an informed choice
for him/herself. |
Rev.
2 05-98 V-26
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A408 |
(3) Delay in examination or treatment. A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (c) in order to inquire about the individual's method of payment or insurance status. |
INTERPRETIVE GUIDELINES: §489.24(c)(3)
Hospitals should not delay in providing a medical
screening examination or necessary stabilizing treatment by inquiring about
an individual's ability to pay for care. All individuals who have an emergency medical condition
must be served, regardless of the answers the individual may give to the
insurance questions asked during the registration process. In addition, a hospital may not delay
screening or treatment to any individual while it verifies the information
provided. However, hospitals may
continue to follow reasonable registration processes for individuals
presenting with an emergency medical condition. Reasonable registration processes may include requesting
information about insurance as long as these procedures do not delay
screening or treatment. If a delay in screening was due to an unusual internal crisis
whereby it was simply not within the capability of the hospital to provide an
appropriate screening examination at the time the individual came to the
hospital (e.g., mass casualty occupying all the hospital's resources for a
time period), interviews with staff members should elicit this information.
This requirement applies equally to both the referring and the
receiving (recipient) hospital. |
A409 |
(d)
Restricting transfer until the individual is stabilized.-- (1)
General. If
an individual at a hospital has an emergency medical condition that has not
been stabilized (as defined in paragraph (b) of this section), the hospital
may not transfer the individual unless-- (i)
The transfer is an appropriate transfer (within the meaning of paragraph
(d)(2) of this section); and |
INTERPRETIVE
GUIDELINES: §489.24(d)(1) (See
the definition of "Stable
for transfer"
at Tag A407) INTERPRETIVE
GUIDELINES: §489.24(d)(1)(i) There
are 4 requirements of an "appropriate" transfer. These requirements are found in
§§489.24(d)(2)(i), 489.24(d)(2)(ii), 489.24(d)(2)(iii), and
489.24(d)(2)(iv). |
Rev.
2 05-98 V-27
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A409 (Cont.) |
(ii)(A)
The individual (or a legally responsible person acting on the individual's
behalf) requests the transfer after being informed of the hospital's obligations
under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the
request as well as indicate that he or she is aware of the risks and benefits
of the transfer; |
INTERPRETIVE
GUIDELINES: §489.24(d)(1)(ii)(A) The
request must contain a brief statement of the hospital's obligations under
the statute and the benefits and risks that were outlined to the person
signing the request. Any
transfer of an individual with an emergency medical condition must be
initiated by either a written request for transfer or a physician's
certification. If both are provided
(as is often the case), the individual must still be informed of the risks
vs. benefits of the transfer. The
request must be made a part of the individual's medical record, and a copy of
the request should be sent to the receiving (recipient) facility along with
the individual transferred. If
an individual's request for transfer is obtained by coercion or by
misrepresenting the hospital's obligations to provide a medical screening
examination and treatment for an emergency medical condition or labor, the
request does not meet the hospital's obligations under these regulations. |
A409 (Cont.) |
(ii)(B)
A physician (within the meaning of §1861(r)(1) of the Act) has signed a
certification that, based upon the information available at the time of
transfer, the medical benefits reasonably expected from the provision of
appropriate medical treatment at another medical facility outweigh the
increased risks to the individual or, in the case of a woman in labor, to the
unborn child, from being transferred.
The certification must contain a summary of the risks and benefits
upon which it is based; or |
INTERPRETIVE
GUIDELINES: §489.24(d)(1)(ii)(B) Section
1861(r) of the Act defines physicians as: (i) A doctor of medicine or osteopathy. (This provision is not to be construed to
limit the authority of a doctor of medicine or osteopathy to delegate tasks
to other qualified health care personnel to the extent recognized under State
law or a State's regulatory mechanism); (ii) A doctor of dental surgery or dental
medicine who is legally authorized to practice dentistry by the State and who
is acting within the scope of his or her license; (iii) A doctor of podiatric medicine, but only
with respect to functions which he or she is legally authorized by the State
to perform; (iv) A doctor of optometry who is legally
authorized to practice optometry by the State, but only with respect to
services related to the condition of aphakia; or (v) A chiropractor who is licensed by the
State or legally authorized to perform the services of a chiropractor, but
only with respect to treatment by means of manual manipulation of the spine
to correct a subluxation demonstrated by X-ray to exist. |
Rev.
2 05-98 V-28
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A409
(Cont.) |
|
The
regulation requires an express written certification. Physician certification cannot
simply be implied from the findings in the medical record and the fact that
the patient was transferred. The
certification must state the reason(s) for transfer. The narrative rationale need not be a
lengthy discussion of the individual's medical condition reiterating facts
already contained in the medical record, but it should give a complete
picture of the benefits to be expected from appropriate care at the receiving
(recipient) facility and the risks associated with the transfer, including
the time away from an acute care setting necessary to effect the transfer. This
rationale may be on the certification form or in the medical record. In cases where the individual's medical
record does not include a certification, give the hospital the opportunity to
retrieve the certification.
Certifications may not be backdated.
Document the hospital's response. Regardless
of practices within a State, a woman in labor may be transferred only if she
or her representative requests the transfer or if a physician or other
qualified medical personnel signs a certification that the benefits outweigh
the risks. If the hospital does not
provide obstetrical services, the benefits of a transfer may outweigh the
risks. A hospital cannot cite State
law or practice as the basis for the transfer. Hospitals
that are not capable of handling high-risk deliveries or high-risk infants
often have written transfer agreements with facilities capable of handling
high-risk cases. The hospital must
still meet the screening, treatment, and transfer requirements. The
certification that the benefits reasonably expected from the provision of
appropriate medical treatment at another medical facility outweigh the risk
of the transfer is not required for transfers of individuals who no longer
have an emergency medical condition. The
date and time of the physician certification should closely match
the date and time of the transfer. |
Rev.
2 05-98 V-29
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A409 (Cont.) |
(c)
If a physician is not physically present in the emergency department at the
time an individual is transferred, a qualified medical person (as determined
by the hospital in its by-laws or rules and regulations) has signed a
certification described in paragraph (d)(1)(ii)(B) of this section after a
physician (as defined in section 1861(r)(1) of the Act), in consultation with
the qualified medical person, agrees with the certification and subsequently
countersigns the certification. The
certification must contain a summary of the risks and benefits upon which it
is based. |
INTERPRETIVE
GUIDELINES: §489.24(d)(1)(C) Individuals
other than physicians may sign the certification of benefits versus risks of
a transfer. These individuals must be
identified in hospital bylaws, rules and regulations, or another
board-approved document . If
a certification of benefits versus risks was signed by a qualified medical
person, a physician's countersignature must be present. Hospital by-laws or policies and
procedures will describe the maximum amount of time allowed to obtain
physician countersignatures on hospital documents. |
|
(d)(2)
A TRANSFER to another medical
facility will be APPROPRIATE only
in those cases in which-- (i)
The transferring hospital provides medical treatment within its capacity that
minimizes the risks to the individual's health and, in the case of a woman in
labor, the health of the unborn child; |
INTERPRETIVE
GUIDELINES: §489.24(d)(2)(i) This
is the first requirement of an appropriate transfer. The
provision of treatment to minimize the risks of transfer is merely one of the
4 requirements of an appropriate transfer.
If the patient requires treatment, it must be sufficient so
that no material deterioration is likely to occur or result from the
transfer. NOTE: The 4 requirements of an
"appropriate" transfer are applied only if the transfer is to
another medical facility. In other
words, the hospital has the alternative of either (1) providing treatment to
stabilize the emergency medical condition and subsequently discharging or
transferring the individual, or (2) appropriately transferring an
unstabilized individual to another medical facility if the emergency medical
condition still exists. There is no
"third" option of simply "referring" the individual away
after performing step one (treatment to minimize the risk of transfer) of the
4 transfer requirements of an appropriate transfer. |
Rev.
2 05-98 V-30
INTERPRETIVE GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A409
(Cont.) |
|
If a patient is moved to another part of the hospital, the transfer requirements are not applicable because technically the patient has not been transferred. If
an individual is moved to a diagnostic facility owned by
another hospital with the intention of returning to the first hospital,
an appropriate transfer (within the meaning of paragraph (d)(2) of this
subsection) must still be effectuated.
For example, when Hospital A shares a CT Scanner with Hospital B
(Hospital B houses the CT Scanner), if Hospital A sends the individual to
Hospital B for a CT scan as part of the appropriate medical screening
examination to determine whether the individual has an emergency medical
condition, the appropriate transfer requirements must be met. After
the investigation of the transferring hospital, call or go to the receiving
(recipient) facility and determine whether the receiving (recipient) facility
verifies the transferring hospital's information. In cases of discrepancy, obtain the medical record from the
transferring and receiving hospitals and the ambulance service for
review. Review each hospital's
information. If you determine that it
is necessary to conduct a complaint investigation at the receiving
(recipient) hospital, notify the RO to request an extension of the
investigation timeframe. Review
the transfer logs for the entire hospital, not merely the emergency
department. Examine the following for
appropriate transfers: o Transfers to off-site testing
facilities and return; o Death or significant adverse outcomes; o Refusals of examination, treatment, or
transfer; o Patients leaving against medical advise
(AMA); o Returns to the emergency department
within 48 hours; and o Emergency department visits where the patient is logged in for an unreasonable amount of time before the time indicated for commencement of the medical screening examination. |
|
|
|
Rev.
2 05-98 V-31
INTERPRETIVE
GUIDELINES-RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN EMERGENCY
CASES |
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A409 (Cont.) A409
(Cont.) A409
(Cont.) |
(ii)
The receiving facility -- (A) Has available space and qualified personnel for
the treatment of the individual; and (B) Has agreed to accept transfer of the
individual and to provide appropriate medical treatment; (iii)
The transferring hospital sends to the receiving facility all medical records
(or copies thereof) related to the emergency condition which the individual has
presented that are available at the time of the transfer, including available
history, records related to the individual's emergency medical condition,
observations of signs or symptoms, preliminary diagnosis, results of
diagnostic studies or telephone reports of the studies, treatment provided,
results of any tests and the informed written consent or certification (or
copy thereof) required under paragraph (d)(1)(ii) of this section, and the
name and address of any on-call physician (described in paragraph (f) of this
section) who has refused or failed to appear within a reasonable time to
provide necessary stabilizing treatment.
Other records (e.g., test results not yet available or historical
records not readily available from the hospital's files) must be sent as soon
as practicable after transfer; and (iv)
The transfer is effected through qualified personnel and transportation
equipment, as required, including the use of necessary and medically
appropriate life support measures during the transfer. |
INTERPRETIVE
GUIDELINES: §489.24(d)(2)(ii) This
is the second requirement of an appropriate transfer. The
transferring hospital must obtain permission from the receiving (recipient)
hospital to transfer an individual.
The transferring hospital should document its communication with the
receiving (recipient) hospital, including the date and time of the transfer
request and the name of the person accepting the transfer. INTERPRETIVE
GUIDELINES: §489.24(d)(2)(iii) This
is the third requirement of an appropriate transfer. Individuals
being transferred to another hospital must be accompanied by necessary
medical records. To
the extent that services are performed before transfer, those services should
be reflected in the medical records transferred. If
transfer is in an individual's best interest, it should not be delayed until
records are retrieved or test results come back from the laboratory. Whatever medical records are available at
the time the individual is transferred should be sent to the receiving
(recipient) hospital with the patient.
Test results that become available after the individual is transferred
should be telephoned to the receiving (recipient) hospital, and then mailed
or sent via electronic transmission. INTERPRETIVE
GUIDELINES: §489.24(d)(2)(iv) This
is the fourth requirement of an appropriate transfer. Emergency
medical technicians may not always be "qualified personnel" for
purposes of transferring an individual under these regulations. Depending on the individual's condition,
there may be situations in which a physician's presence or some other
specialist's presence might be mandatory.
The physician at the sending hospital (and not the receiving
hospital) has the responsibility to determine appropriate mode, equipment,
and attendants for transfer. |
Rev.
2 05-98
V-32
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A409
(Cont.) A410 |
(4)
Refusal to consent to transfer.
A hospital meets the requirements of paragraph (c)(1)(ii) of this
section with respect to an individual if the hospital offers to transfer the
individual to another medical facility in accordance with paragraph (d) of
this section and informs the individual (or a person acting on his or her
behalf) of the risks and benefits to the individual of the transfer, but the
individual (or a person acting on the individual's behalf) refuses to consent
to the transfer. The hospital must
take all reasonable steps to secure the individual's written informed refusal
(or that of a person acting on his or her behalf). The written document must indicate the person has been informed
of the risks and benefits of the transfer and the reasons for the
individual's refusal. The medical
record must contain a description of the proposed transfer that was refused
by or on behalf of the individual. (3)
A participating hospital may not penalize or take adverse action against a
physician or a qualified medical person described in paragraph (d)(1)(ii)(C)
of this section because the physician or qualified medical person refuses to
authorize the transfer of an individual with an emergency medical condition
that has not been stabilized, or against any hospital employee because the
employee reports a violation of a requirement of this section. |
While
the hospital is ultimately responsible for ensuring that the transfer is
effected appropriately, the hospital may meet its obligations as it sees
fit. These regulations do not require
that a hospital operate an emergency medical transportation service. INTERPRETIVE
GUIDELINES: §489.24(c)(4) A
hospital cannot be left without recourse if an individual or the individual's
representative refuses transfer and also refuses to sign a statement to that
effect. Hospitals may document such
refusals as they see fit. INTERPRETIVE
GUIDELINES: §489.24(d)(3) A
"participating hospital" means a hospital that has entered into a
provider agreement under §1866 of the Act. |
Rev.
2 05-98 V-33
INTERPRETIVE
GUIDELINES - RESPONSIBILITIES OF MEDICARE PARTICIPATING HOSPITALS IN
EMERGENCY CASES |
||
TAG NUMBER |
REGULATION |
GUIDANCE
TO SURVEYORS |
A411 |
(e)
Recipient hospital responsibilities.
A participating hospital that has specialized capabilities or
facilities (including, but not limited to such facilities as burn units,
shock-trauma units, neonatal intensive care units, or (with respect to rural areas)
regional referral centers) may not refuse to accept from a referring hospital
within the boundaries of the United States, an appropriate transfer of an
individual who requires such specialized capabilities or facilities if the
receiving hospital has the capacity to treat the individual. |
INTERPRETIVE
GUIDELINES: §489.24(e) Recipient
hospitals only have to accept the patient if the patient requires the
specialized capabilities of the hospital in accordance with this
section. If the transferring hospital
wants to transfer a patient because it has no beds or is overcrowded, but the
patient does not require any "specialized" capabilities, the
receiving (recipient) hospital is not obligated to accept the patient. If the patient required the specialized
capabilities of the intended receiving (recipient) hospital, and the hospital
had the capability and capacity to accept the transfer but refused, this
requirement has been violated. Lateral
transfers, that is, transfers between facilities of comparable resources, are
not sanctioned by §489.24 because they would not offer enhanced care benefits
to the patient except where there is a mechanical failure of equipment, no
ICU beds available, or similar situations.
However, if the sending hospital has the capability but not the
capacity, the individual would most likely benefit from the transfer. The
number of patients that may be occupying a specialized unit, the number of
staff on duty, or the amount of equipment on the hospital's premises do not
in and of themselves reflect the capacity of the hospital to care for
additional patients. If a hospital
generally has accommodated additional patients by whatever means (e.g.,
moving patients to other units, calling in additional staff, borrowing
equipment from other facilities), it has demonstrated the ability to provide
services to patients in excess of its occupancy limit. For example, a hospital may be able to
care for one or more severe burn patients without opening up a "burn
unit." In this example, if the
hospital has the capacity, the hospital would have a duty to accept an
appropriate transfer of an individual requiring the hospital's capabilities,
provided the transferring hospital lacked the specialized services to treat
the individual. The
provisions of this requirement are applicable only when the sending hospital
is located within the boundaries of the United States. Medicare participating hospitals with
specialized capabilities or facilities are not obligated to accept transfers
from hospitals located outside of the boundaries of the United States. RURAL
REGIONAL REFERRAL CENTERS The
criteria for classifying hospitals as rural regional referral centers have
been defined in 42 CFR 412.96 for the purpose of exemptions and adjustments
of payment amounts under the Prospective Payment System. The criteria in 42 CFR 412.96 are
applicable to the nondiscrimination provisions of §489.24. Check with the Division of Medicaid
and State Operations in the appropriate HCFA RO for information as to
whether the hospital is designated as a rural regional referral center. A designated rural regional referral
center is obligated to accept appropriate transfers of individuals who
require the hospital's specialized capabilities if the hospital has the
capacity to treat the individual. |
Rev.
2 05-98
V-34