Emergency and Urgently Needed Provider Services, and Out of

80 - Emergency and Urgently Needed Provider Services, and Out of Area Provider Services for Which the Cost-Based HMO/CMP Assumes Financial Responsibility (Rev. 4, 10-01-01) The Medicare FFS system may pay the providers for the reasonable cost of covered emergency or urgently needed services and other covered out of area services for which the cost-based HMO/CMP assumes financial responsibility and which are furnished to the HMO/CMP’s Medicare enrollees. Alternatively, the HMO/CMP may reimburse a provider for these services, in which case payment will be made to the HMO/CMP through the cost reporting mechanism. However, payment to the HMO/CMP for such services is allowable only to the extent that it does not exceed the reasonable cost for the service or Medicare’s prospective payment for the service, as defined in 42 CFR, Parts 405, 412, and 413. Exception: Payment in excess of the amount allowed under 42 CFR, Parts 405, 412, and 413 may be made if the HMO/CMP demonstrates to CMS’s satisfaction that the excess payment is justified on the basis of advantages gained by the HMO/CMP. (See 42 CFR 417.558.)