Form Cms-2628 - Foreign Hi Claim Or Emergency Services Accessibility Documentation And Determination

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FOREIGN HI CLAIM OR EMERGENCY SERVICES ACCESSIBILITY DOCUMENTATION AND DETERMINATION
1. PATIENT’S NAME
2. HI CLAIM NUMBER
3. PATIENT RESIDENCE ADDRESS
4. ADMITTING HOSPITAL’S NAME AND ADDRESS
5. HOSPITAL’S EMERGENCY NUMBER
(domestic only)
PART I – ACCESSIBILITY DOCUMENTATION — COMPLETE ALL SECTIONS
SECTION A – LOCATION OF BENEFICIARY WHEN EMERGENCY OCCURRED (Answer 1-2 for domestic, 3-6 for foreign hospital)
Beneficiary was considered to require emergency services when
ADDRESS AND/OR SITE
OF CHECKED LOCATION
J
1.
Emergency was “Self-evident” (e.g. sudden change in state
of consciousness, sudden onset of severe pain or bleeding, etc.)
J
2.
The physician, by seeing beneficiary or by telephone contact,
first decided emergency services were required.
3. DISTANCE FROM
4. NAME AND ADDRESS OF NEAREST PARTICIPATING
5. DISTANCE OF
BENEFICIARY’S RESIDENCE
U.S. HOSPITAL TO BENEFICIARY’S RESIDENCE
PARTICIPATING HOSPITAL
TO ADMITTING HOSPITAL
FROM BENEFICIARY’S RESIDENCE
6. CHECK EITHER A OR B
J
A.
The foreign hospital is not more than 15 miles farther from the beneficiary’s residence than the nearest participating U.S. hospital.
J
B.
The foreign hospital is more than 15 miles farther from the beneficiary’s residence than the nearest participating U.S. hospital.
SECTION B – ALTERNATIVE HOSPITALS (Answer either 1 or 2; always answer 3) — Domestic emergency claims only
Participating hospital 15 or fewer miles farther from the location of the emergency than is the
J
1.
admitting non-participating hospital (as determined in Section A) — Answer A, B and C.
A. DISTANCE TO ADMITTING
B. DISTANCE TO PARTICIPATING
C. NAME AND ADDRESS OF PARTICIPATING
HOSPITAL FROM LOCATION
HOSPITAL CLOSER TO LOCATION
HOSPITAL CLOSEST TO LOCATION OF EMERGENCY
OF EMERGENCY
OF EMERGENCY
Participating hospital more than 15 miles farther from the location of the emergency than is the
. J
2
admitting non-participating hospital (as determined in Section A) (If checked, omit Section C.)
3. List the participating hospital closest to the admitting hospital:
A. NAME AND ADDRESS
B. DISTANCE BETWEEN TWO HOSPITALS
SECTION C – SPECIAL CIRCUMSTANCES (domestic claims—do not complete this section if section b, item 2 is checked)
(Foreign claims—include an explanation in “Remarks” or an attachment for each item checked.)
J
1. J
4.
Needed equipment or personnel unavailable in
Bed unavailable in nearest participating hospital
nearest participating hospital
J
2.
Nearest participating hospital would not
J
5.
Other factors
accept patient
J
3.
Geographic difficulties
J
6.
Unusual medical circumstances indicated; e.g.,
shock, loss of blood, etc. (domestic claims only)
Form CMS-2628 (05/86) EF 11/2005

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