2015 Dual Difference Plan Update

2015 Dual Difference Plan Update/Clarification

Pre-Authorization Requirement

Independent Health removed pre-authorization from our Dual Difference plan as of January 1, 2015.

We have since learned we should have retained the pre-authorization requirement on Dual Difference. Therefore, we will reinstate the pre-authorization requirement as of February 23, 2015*.

We realize you may have scheduled services without obtaining pre-authorization based on previous information. We apologize for any inconvenience or confusion this may cause your practice. If any of your Dual Difference patients have procedures that require pre-authorization scheduled on or after February 23, 2015, you will need to obtain pre-authorization from Independent Health. If a provider does not obtain pre-authorization, the claim will deny.

Referral Clarification

Referrals are not required for any services for Dual Difference members.

Skilled Nursing Facility Stay

We also wanted to make you aware that Dual Difference now requires a medically-necessary minimum three-day hospital inpatient stay before members enter a skilled nursing facility. This requirement follows Original Medicare.

If a partially eligible Dual Difference member enters a skilled nursing facility without having the minimum three day hospital inpatient stay, the member will be responsible for paying the entire skilled nursing facility bill. If a fully eligible Dual Difference member enters a skilled nursing facility without having the minimum three day hospital inpatient stay, then the facility should bill Medicaid.

All other Medicare Advantage plans are not subject to this benefit change.

About Dual Difference

Independent Health’s Dual Difference is offered to members who are Medicare beneficiaries who are also eligible for Medicaid. Check ePACES for member eligibility.

  • Partially eligible Dual Difference member: a member who receives a subsidy for their Medicare Part B premiums only and not Medicaid medical benefits.
  • Fully eligible Dual Difference member: member who receives Medicare and full Medicaid benefits.

If you have questions, please contact our Provider Service department by calling (716) 631-3282 or 1-800-736-5771, Monday through Friday from 8 a.m. to 6 p.m.

*This is an update to an earlier communication, which had indicated February 16.