Tell patients about possible noncoverage before providing service, treatment or item

If you and your patient decide that the best course of care for him or her may not be covered by Medicare Plus Blue^SM PPO, you’re required to inform the patient of possible noncoverage before performing the service or treatment or obtaining the item. If the patient decides to pursue the noncovered course of care knowing it won’t be covered by the benefit plan, you must first submit a preservice organization determination (also known as an advance coverage determination) to the plan.

Here’s why
If you don’t provide the patient with notice of possible noncoverage by the plan, and the patient proceeds with the course of care, you may not bill the patient for such noncovered items, treatments or services.
Note: This doesn’t pertain to any of the outlined services that require precertification or prior authorization.

Here’s how
Review the provider responsibilities for noncovered services and referrals for noncovered services in the “Billing Members” section of the Medicare Plus Blue PPO Manual on Page 5. It details the steps recommended for providers to follow when ordering services or procedures that may not be covered by the benefit plan, including how to get an advance coverage determination and when to request an expedited determination. This process resolves any uncertainties for both the provider and patient.

Thank you for your continued support as we strive for excellence in both the provider and the member experience.