Request Medicare PSODs for potentially non-covered services

The Centers for Medicare and Medicaid Services (CMS) rules require all Part C (Medicare Advantage) plans - NOT providers - give a specific written notice to members if a service or item isn't covered prior to the service being rendered. The written notice of non-coverage is called a pre-service organization determination (PSOD). Priority Health launched PSOD education in Fall 2015, and we continue to post information and news articles quarterly to remind providers of this process.

Whether or not the member requests a pre-service organization determination (PSOD), the member can't be held financially responsible for a non-covered service unless there's a clear exclusion in the Evidence of Coverage (EOC) or Priority Health issues a Notice of Denial of Medicare Coverage.

PSOD vs ABN

The PSOD replaced the Advanced Beneficiary Notice (ABN). ABNs are still allowed and used only for members of original, fee-for-service Medicare, but never for Medicare Advantage plans. This is clarified in a CMS memo date May 5, 2014.

The PSOD process

Overall, the PSOD process was created to help Medicare members be 100% informed about their potential financial liability for each service prior to having a medical service completed.

PSOD is required when a provider isn't sure if the service is covered.

PSOD is not required when:

  • The provider knows a service is definitely covered (such as a specific cancer screening or well-visit)
  • The provider knows the service definitely isn't covered (the service is outlined as an exclusion in the plan's EOC, such as immunizations or drugs covered under Part D Medicare only)

Provider offices are encouraged to use our Edits Checker tool to help identify whether a PSOD is necessary or not.

Go to information on Requesting a Medicare pre-service organization determination.

Appealing a PSOD that denies coverage

Recently, we have seen an increase in appeals due to providers appealing based upon medical necessity when they didn't follow the PSOD process.

If a provider chooses to appeal a claim that has denied for a Medicare local coverage determination (LCD) or national coverage determination (NCD), the provider must include a copy of  the completed PSOD with the appeal. We will no longer review provider appeals for LCDs/NCDs if a PSOD was not included. 

For more information, go to the webpage on appealing a PSOD-generated Notice of Denial.