Reminder: Advance Beneficiary Notices banned under Medicare Advantage rules
Provider organizations should be aware that since May 2014 an Advanced Beneficiary Notice of Non-Coverage (ABN) is not a valid form of denial notification for Medicare Advantage plan members. ABNs, sometimes referred to as "waivers," are used in the Original Medicare program. However, you can't use them for patients enrolled in Priority Health Medicare plans, as the Centers for Medicare and Medicaid Services (CMS) prohibits use of ABNs or ABN-like forms.
Providers must understand what services are covered
As a provider who has elected to participate in the Medicare program, you need to understand which services are covered by Original Medicare and which are not. Priority Health Medicare plans are required to cover everything that Original Medicare covers, and in some instances may provide coverage that is more generous or otherwise goes beyond what is covered under original Medicare.
As a Priority Health Medicare contracted provider, you are also expected to understand what is covered under Priority Health Medicare.
Pre-service organization determinations are provided by Priority Health
CMS mandates that providers who are contracted with a Medicare Advantage plan, such as Priority Health, are not permitted to hold a Medicare Advantage member financially responsible for payment of a service not covered under the member's Medicare Advantage plan unless that member has received a pre-service organization determination (PSOD) notice of denial from Priority Health before such services are rendered.
PSODs can be initiated by you as the provider or by the member in order to determine if the requested/ordered service is covered prior to a member receiving it, or prior to scheduling a service such as a lab test diagnostic test, or procedure.
If the member does not have a PSOD notice of denial from Priority Health on file, you must hold the member harmless for the non-covered services and cannot charge the member any amount beyond the normal cost-sharing amounts (i.e., copayments, coinsurance, and/or deductibles).
PSODs are not needed for EOC exclusions and other clearly excluded services
Where a service is never covered under original Medicare or is listed as a clear exclusion in the member's Evidence of Coverage (EOC) or other similar plan document, a pre-service organization determination is not required in order for you to hold the member financially liable for such non-covered services.
Please note, services or supplies that are not medically necessary or are otherwise determined to be not covered based on clinical criteria do not constitute "clear exclusions" under the member's plan, as the member is not likely to be able to ascertain on the face of the EOC that such services will not be covered.
Holding members responsible
Remember, unless a service or supply is never covered under Original Medicare, you will only be able to hold a Priority Health Medicare member financially responsible for a non-covered service if the member has received a PSOD denial from Priority Health and decides to proceed with the service knowing they will be financially liable.
Learn more about Medicare non-coverage and the pre-service organization determination process in the Medicare non-coverage.