EMTALA billing rules: what hospitals and ERs must know

What does EMTALA require of a hospital emergency department?

EMTALA, the Emergency Medical Treatment and Labor Act, is a federal law that Medicare enforces through the hospital's provider agreement. Under 42 CFR 489.24(a)(1), when any individual comes to a hospital's emergency department, the hospital must provide an appropriate medical screening examination within the capability of the department, including ancillary services routinely available to it. The duty applies whether or not the person is eligible for Medicare and regardless of ability to pay.

If the screening shows an emergency medical condition, the hospital must provide the stabilizing treatment it can within its staff and facilities, or make an appropriate transfer. Under 489.24(d)(2), the duty ends on a good-faith inpatient admission to stabilize the condition.

Who does EMTALA apply to: hospitals, freestanding ERs and urgent care?

EMTALA applies to a Medicare participating hospital that has a dedicated emergency department. The definition of hospital in 489.24(b) includes critical access hospitals and rural emergency hospitals. A department counts as a dedicated emergency department if it meets any one of three tests, whether it sits on or off the main campus.

• It is licensed by the state as an emergency room or emergency department.
• It is held out to the public, by name, signs or advertising, as a place that treats emergency medical conditions on an urgent basis without an appointment.
• In the calendar year before the determination, at least one-third of its outpatient visits were for emergency medical conditions on an urgent basis without a previously scheduled appointment.

That wording decides the freestanding question. A freestanding ER that is a department of a hospital can be covered, because the test looks at the department and not the building. An independent freestanding emergency department, one that is geographically separate and licensed separately from a hospital under 45 CFR 149.30, is not a hospital under 489.24. The No Surprises Act rules still borrow the same standard for it, as the next section shows. Our freestanding ER billing guide covers how they bill.

Urgent care follows the same logic. A standalone urgent care that is not part of a hospital sits outside 489.24, while a hospital department that meets one of the three tests does not.

Can an ER ask for insurance information before the screening exam?

Yes, as long as the question does not delay the exam or treatment. Under 489.24(d)(4)(iv), a hospital may follow reasonable registration processes, including asking whether the person is insured and what the insurance is, if that inquiry does not delay screening or treatment.

The regulation never mentions copayments. Its test is whether a request for money delays care or discourages the patient from staying. Many hospitals ask after the exam. Set the policy with compliance or counsel; this page is not legal advice.

Does EMTALA prevent you from billing the patient or the insurer?

No part of 489.24 bars billing for the visit. The regulation controls timing and conduct: no payment-driven delay, no early authorization requests, no discouraging patients.

After the exam, the claim follows normal payer rules. The hospital reports the visit on the UB-04 with revenue code 0450 and the ED visit code for its level, from 99281 through 99285 for a Type A emergency department. How a hospital picks that level is on our ED facility level coding page.

Authorization is where billing staff most often slip. Because 489.24(d)(4)(ii) bars asking before the exam and the start of stabilizing treatment, an authorization rule cannot hold a patient.

How does EMTALA interact with the No Surprises Act?

EMTALA decides what care a hospital must provide, and the No Surprises Act decides what an insured patient can be billed for it. 45 CFR 149.110(c)(2)(i) defines emergency services as the screening exam required by section 1867 of the Social Security Act, plus the further exam and treatment needed to stabilize the patient. For an independent freestanding emergency department, the wording applies as if section 1867 applied to it.

The NSA definition also reaches past stabilization. Under 149.110(c)(2)(ii), out-of-network items and services after the patient is stabilized, during the same visit and as part of observation or a stay, are emergency services too, unless every condition in 149.410(b) is met. Those include the treating provider's finding that the patient can travel to a participating facility and a signed notice and consent. Our notice and consent page walks through that.

The billing limit sits in 45 CFR 149.410(a). A nonparticipating emergency facility, and a nonparticipating provider at it, must not bill a person with group or individual health coverage more than the in-network cost-sharing amount for emergency services. The rest is settled between plan and facility under the process on our No Surprises Act pages.

What documentation supports EMTALA compliance on a claim?

The record has to show that the screening exam happened and what followed. 489.24 names the entries below.

What happens if a hospital violates EMTALA?

CMS can terminate the hospital's Medicare provider agreement under 489.53, as 489.24(g) provides. For cases that need a medical opinion, CMS asks the quality improvement organization (QIO) to review the alleged violation. The Office of Inspector General can impose civil monetary penalties or an exclusion under section 1867(d)(1) of the Social Security Act.

Under 489.24(h)(2), the QIO gives written notice by certified mail within 15 calendar days of receiving the case. The notice invites the physician and the hospital to meet with the QIO and to submit more information within 30 calendar days of receipt, which is presumed 5 days after the certified mail date. The right to be heard is waived if the invitation is not accepted.

EMTALA exposure is a compliance matter, so there is no remark code to appeal. Claim problems from the same visit follow the ordinary path in Medicare appeal levels. If this rule is costing you claims, our denial management team can help.