14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.5 Provider Obligations - In-office Denials
In the event a member disagrees with the provider’s decision about a request for service or a course of treatment or is requesting or in need of services that are not covered by the plan or Medicare. At each patient encounter with a Medicare member, the provider must notify the member of his or her right to receive, upon request, a detailed written notice from IntegraNet regarding the member’s services. The provider must request us to provide a detailed notice of a provider’s decision to deny a service in whole or part; in turn, we must give the member advanced written notice of the determination, by following the precertification process (outlined below).
For services that require prior authorization or are noncovered by the plan (i.e., statutory exclusion), it becomes extremely important that IntegraNet authorization procedures are followed. If a member elects to receive such care the member cannot be held financially responsible unless notified in advance of the noncovered services. In such cases when the network physician fails to follow IntegraNet authorization protocols, IntegraNet may decline to pay the claim in which case the physicians will be held financially responsible for services received by the member. Again, CMS prohibits holding the member financially responsible in these cases.
The CMS has established guidelines concerning Advance Notices of Non-Coverage (ABN). The ABN is a FFS document and cannot be used for Medicare Advantage denials or notifications. Per CMS, The ABN is given to beneficiaries enrolled in the Medicare Fee-For-Service (FFS) program. It is not used for items or services provided under the Medicare Advantage (MA) Program or for prescription drugs provided under the Medicare Prescription Drug Program (Part D). CMS advised Medicare Advantage plans that contracted providers are required to provide a coverage determination for services that are not covered by the member’s Medicare Advantage plan. This will ensure that the member will receive a denial of payment and accompanying appeal rights. If there is any doubt about whether a service is not covered, please seek a coverage determination from the plan.
A written coverage determination will help ensure that a claim for noncovered care from a contracted provider is paid accurately. According to CMS, if the appropriate written notice of denial of payment is not given to the Medicare Advantage member regarding a noncovered service, the claim may be denied, and the member cannot be held financially responsible. Therefore, your failure to provide an appropriate coverage determination could result in a denial of payment for the noncovered service.
Please contact IntegraNet prior to services being rendered to comply with this requirement and ensure appropriate claims payment and allow you to bill the Medicare member in the event of noncoverage. As a contracted provider with IntegraNet, you are prevented from billing the Medicare member for any service that is deemed non-covered if you have not ensured this advanced notification has been issued.