Page 33 - Medicare Benefit Policy Manual

A3-313, HO-260.14, B3-2370

The program may not pay for items and services for which payment has been made or
can reasonably be expected to be made promptly under a liability, automobile, no-fault or
workers’ compensation law or plan of the United States or a State. Also, payments for
items and services under the health insurance program are subject to repayment to the
appropriate trust fund if notice or information is received that payment is available for the
items and services under a liability, automobile, no-fault or workers’ compensation plan.

See the MSP manual for specific instructions.

170 - Inpatient Hospital or SNF Services Not Delivered Directly or
Under Arrangement by the Provider
(Rev. 1, 10-01-03)
A3-3164, HO-260.15, B3-2390, PM A 00-88

Nonphysician services provided to a Part A inpatient or Part B inpatient of a hospital or
to a Part A inpatient of a SNF which are not provided directly by the hospital/SNF or
under arrangement generally are excluded from coverage under Medicare.

This coverage exclusion does not apply to the following types of services:

• Physicians’ services for hospital inpatients or physician’s services other than
therapy for SNF inpatients (i.e., therapy provided by physicians is not covered for
any SNF Part A and Part B inpatient unless provided by the SNF, but other
physician services may be covered. Any normally-covered service may be
provided by a physician to a hospital inpatient);

• Physician assistant services;

• Nurse practitioners and clinical nurse specialists;

• Certified nurse-midwife services;

• Qualified clinical psychologist services;

• Certified registered nurse anesthetist; and

• Services of an anesthetist employed by a physician that were furnished during
cost reporting periods beginning on or after October 1, 1984, through any part of a
cost reporting period occurring before January 1, 1989.

The A/B MAC (B) may make direct payment on Part B bills for these services, if they are
medically necessary, even though they are not furnished directly or arranged for by the
hospital/SNF.