Reminder: PSODs are required for procedures, services that may not be covered by Medicare
Pre-service organization determinations (PSODs) are requests used to determine whether an item or service will be covered for a Medicare member.
The PSOD process is like the Traditional Medicare Advanced Beneficiary Notice (ABN) process, protecting all parties involved – the member, provider and Priority Health.
Ensure services not covered, but chosen by the member, don’t become provider liability
When the requested service is covered, we’ll provide the required confirmation. When it’s not covered, we’ll send the Notice of Denial of Medicare Coverage (CMS-10003) to the provider and member. This notice lets the member know they’ll be liable for the cost if they pursue the service.
Bill with modifier GA if the Medicare member decides to move forward with the service knowing coverage has been denied. This will make sure the balance goes to member liability rather than provider liability.
The member, their representative or their provider have the right to request a PSOD.