Advanced Beneficiary Notice update
On May 5, 2014, the Centers for Medicare and Medicaid Services (CMS) released a bulletin noting that the use of the Advanced Beneficiary Notice (ABN) form for Medicare Advantage enrollees is prohibited.
Unlike members enrolled in the Fee-for-Service (Original) Medicare program, Medicare Advantage (MA) enrollees have the option to obtain a coverage decision prior to obtaining the item or service. This coverage review is a request for a pre-service organization determination. The MA plan will review the request and issue either an approval or denial based on its review of the requested item or service.
- If a member is seeking services covered under Original Medicare or the Medicare Advantage plan, a pre-service organization determination is not required (keeping in mind that this does not negate the pre-authorization requirement if a service requires that).
- If a member is seeking services that are either statutorily non-covered services under Original Medicare or non-covered by the MA plan, a pre-service organization determination is required to protect the member.
It's important to note that either the enrollee or the provider can request an organizational determination, but Moda encourages our contracted providers to use our current structure for requesting a pre-service organization determination on the enrollee's behalf.
If a service is denied, the MA member will be better informed to choose if they wish to appeal the denial or would still like to obtain the service at their own expense. If a member chooses to proceed with the service (after exhausting the appeals process or deciding not to pursue an appeal), the member and provider can then enter into a private fee arrangement for the denied services or items.
Reminders:
- ABN forms are prohibited from use for MA enrollees.
- The requirement to request an organizational determination applies to MA members regardless as to whether the service is statutorily non-covered by original Medicare or the service is non-covered by the MA Plan.
- If a contracted provider furnishes such non-covered services without the organization determination, the non-covered charges would be subject to provider write-off.
- A pre-service organizational determination is NOT the same process as the MA plan requiring a Prior Authorization (PA). Pre-service organizations are requested by the MA member or provider while PA requirements for certain items/services are set by the MA plan to verify the medical necessity of the item/service before they are performed or dispensed.
To request a pre-service organization determination for MA members, please call 503-243-4496 (toll-free 800-258-2037) or fax 855-637-2666 today.
|