§ 489.24 Special responsibilities of Medicare hospitals in
emergency cases. 

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(b) * * * Comes to the emergency department means, with
respect to an individual requesting examination or
treatment, that the individual is on the hospital property.
For purposes of this section, ‘‘property’’ means the entire
main hospital campus as defined in § 413.65(b) of this
chapter, including the parking lot, sidewalk, and driveway,
as well as any facility or organization that is located off
the main hospital campus but has been determined under §
413.65 of this chapter to be a department of the hospital.
The responsibilities of hospitals with respect to these off-
campus facilities or organizations are described in
paragraph (i) of this section. Property also includes
ambulances owned and operated by the hospital even if the
ambulance is not on hospital grounds. An individual in a
nonhospital-owned ambulance on hospital property is
considered to have come to the hospital’s emergency
department. An individual in a nonhospital-owned ambulance
off hospital property is not considered to have come to the
hospital’s emergency department even if a member of the
ambulance staff contacts the hospital by telephone or
telemetry communications and informs the hospital that they
want to transport the individual to the hospital for
examination and treatment. In these situations, the hospital
may deny access if it is in ‘‘diversionary status,’’ that
is, it does not have the staff or facilities to accept any
additional emergency patients. If, however, the ambulance
staff disregards the hospital’s instructions and transports
the individual on to hospital property, the individual is
considered to have come to the emergency department.

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(i) Off-campus departments. If an individual comes to a
facility or organization that is located off the main
hospital campus but has been determined under § 416.35 of
this chapter to be a department of the hospital and a
request is made on the individual’s behalf for examination
or treatment of a potential emergency medical condition as
otherwise described in paragraph (a) of this section, the
hospital is obligated in accordance with the rules in this
paragraph to provide the individual with an appropriate
medical screening examination and any necessary stabilizing
treatment or an appropriate transfer.

(1) Capability of the hospital. The capability of the
hospital includes that of the hospital as a whole, not just
the capability of the off-campus department. Except for
cases described in paragraph (i)(3)(ii) of this section, the
obligation of a hospital under this section must be
discharged within the hospital as a whole. However, the
hospital is not required to locate additional personnel or
staff to off-campus departments to be on standby for
possible emergencies. 

(2) Protocols for off-campus departments. The hospital must
establish protocols for the handling of individuals with
potential emergency conditions at off-campus departments.
These protocols must provide for direct contact between
personnel at the off-campus department and emergency
personnel at the main hospital campus and may provide for
dispatch of practitioners, when appropriate, from the main
hospital campus to the off-campus department to provide
screening or stabilization services.

(i) If the off-campus department is an urgent care center,
primary care center, or other facility that is routinely
staffed by physicians, RNs, or LPNs, these department
personnel must be trained, and given appropriate protocols,
for the handling of emergency cases. At least one individual
on duty at the off-campus department during its regular
hours of operation must be designated as a qualified medical
person as described in paragraph (d) of this section. The
qualified medical person must initiate screening of
individuals who come to the off-campus department with a
potential emergency medical condition, and may be able to
complete the screening and provide any necessary stabilizing
treatment at the off-campus department, or to arrange an
appropriate transfer. 

(ii) If the off-campus department is a physical therapy,
radiology, or other facility not routinely staffed with
physicians, RNs, or LPNs, the department’s personnel must be
given protocols that direct them to contact emergency
personnel at the main hospital campus for direction. Under
this direction, and in accordance with protocols established
in advance by the hospital, the personnel at the off-campus
department must describe patient appearance and report
symptoms and, if appropriate, either arrange transportation
of the individual to the main hospital campus in accordance
with paragraph (i)(3)(i) of this section or assist in an
appropriate transfer as described in paragraphs (i)(3)(ii)
and (d)(2) of this section. 

(3) Movement or appropriate transfer from off-
campus departments—

(i) If the main hospital campus has the capability required
by the individual and movement of the individual to the main
campus would not significantly jeopardize the life or health
of the individual, the personnel at the off-campus
department must assist in arranging this movement. Movement
of the individual to the main campus of the hospital is not
considered a transfer under this section, since the
individual is simply being moved from one department of a
hospital to another department or facility of the same
hospital. 

(ii) If transfer of an individual with a potential emergency
condition to a medical facility other than the main hospital
campus is warranted, either because the main hospital campus
does not have the specialized capability or facilities
required by the individual, or because the individual’s
condition is deteriorating so rapidly that taking the time
needed to move the individual to the main hospital campus
would significantly jeopardize the life or health of the
individual, personnel at the off-campus department must, in
accordance with protocols established in advance by the
hospital, assist in arranging an appropriate transfer of the
individual to a medical facility other than the main
hospital. The protocols must include procedures and
agreements established in advance with other hospitals or
medical facilities in the area of the off-campus department
to facilitate these appropriate transfers. Such a transfer
would require— (A) That there be either a request by or on
behalf of the individual as described in paragraph
(d)(1)(ii)(A) of this section or a certification by a
physician or a qualified medical person as described in
paragraph (d)(1)(ii)(B) or (d)(1)(ii)(C) of this section;
and (B) That the transfer comply with the requirements
described in paragraph (d)(2) of this section. (iii) If the
individual is being appropriately transferred to another
medical facility from the off-campus department, the
requirement for the provision of medical treatment in
paragraph (d)(2)(i) of this section would be met by
provision of medical treatment within the capability of the
transferring off-campus department.