Medicare: Charging patients for non-covered services

The Centers for Medicare & Medicaid (CMS) requires all Medicare members, including Dual Eligible Special Needs Plan (D-SNP) members to know costs prior to receiving non-covered services. This applies to all Medicare Advantage plans including but not limited to plans in Arizona, California, District of Columbia, Delaware, Florida, Hawaii, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Missouri, Mississippi, North Carolina, Nebraska, New Mexico, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, Washington and Wisconsin. You’ll need to request a prior authorization if you know or have reason to believe that a service or item for a Medicare Advantage member may not be covered. 

• We’ll issue an Integrated Denial Notice (IDN) to you or your patient if it’s not covered. The IDN gives the patient their cost for the non-covered service or item and appeal rights. 
• You’ll need to include the GA modifier on your claim, stating that a waiver of liability is on file for the non-covered service. This helps to ensure your claim for the non-covered service is appropriately processed as a member liability.

How to request a prior authorization
Use our Provider Authorization and Notification (PAAN) tool in the UnitedHealthcare Provider Portal to submit a prior authorization request. The PAAN tool doesn’t issue denials. It tells you if a procedure code requires a review or not. For more information, go to uhcprovider.com/paan.

Questions?

• Medicare Coverage Center 
• UnitedHealthcare Administrative Guide

PCA-22-01546-C&S-News