Independent Health wants to inform our Medicare Advantage participating providers that using an Advanced Beneficiary Notice of non-coverage (ABN) for a patient with a Medicare Advantage plan is not in compliance with the Medicare Advantage mandate set forth by the Centers for Medicare & Medicaid Services (CMS).
In order for a Medicare Advantage member to receive a non-covered service, a provider or patient must request an organization determination. This request will produce a denial of coverage through the Independent Health organization determination process where the goal is to issue the member the standardized denial notice with appeal rights (the member has the right to appeal any denial of a service or item). The process is as follows:
- A member or provider may request an organization determination from Independent Health, where we will make a decision about benefits and coverage or about the amount we will pay for the medical services.
- If a pre-determination for a non-covered service is not obtained by you or your patient prior to a non-covered service being provided, Independent Health will issue a denial that would make you, the provider, responsible for the charges for performing the non-covered service without first receiving an organization determination from the plan.
- It is important to note that if a service is never covered by Independent Health and the plan’s Evidence of Coverage (EOC) provided to the member is clear that the service or item is never covered, we are not required to hold the member harmless from the full cost of the service or item. For a service or item that is typically not covered, but could be covered under specific conditions (e.g., dental care that is necessary to treat an illness or injury), the EOC, in and of itself, is not adequate notice of non-coverage for purposes of determining member liability.
All physicians, please note that if you, as a participating provider, refer a member to a non-contracted provider for a service that may be covered by Independent Health upon referral, the member is responsible only for the applicable cost-sharing for that service. As stated in your participating provider agreement, you are required to abide by our policies and procedures, which include coordinating care or working with us prior to referring a member to a non-contracted provider to ensure, to the extent possible, that the member is receiving medically necessary services covered by Independent Health.
This mandate from CMS will be enforced by Independent Health beginning May 1, 2015. These rules are in accordance with Medicare Managed Care Manual, Chapter 4, Section 170.
View the CMS memo that outlines the Chapter 4 mandate »
If you have any questions or need additional information on how to request an organization determination on behalf of a member, 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.