Medicare non-coverage notices

Pre-service organization determinations

The Centers for Medicare and Medicaid Services (CMS) rules require that all Part C (Medicare Advantage) plans - NOT providers - give a specific written notice to members if a service or item isn't covered. The process for getting this written notice of non-coverage from Priority Health is called requesting a pre-service organization determination (PSOD).

The PSOD process differs from the rule for fee-for-service Medicare ("Original Medicare") patients, which allows you, the provider, to give written notice. The Part C rule can be found in the Medicare Managed Care Manual, Section 160, Chapter 4, Benefits and Beneficiary Protections. It applies to all Part C Medicare Advantage plans.

Whether or not the member requests a PSOD, the member can't be held financially responsible for a non-covered service unless there's a clear exclusion in the member's Evidence of Coverage (EOC) plan document, OR Priority Health issues a Notice of Denial of Medicare Coverage.

When a PSOD is not needed

When a service or device is specifically excluded from coverage by the member's Evidence of Coverage document, providers may tell the member that the service will not be covered and the member will be financially responsible for the service or device. No PSOD or form is needed. Document this conversation in the patient's record. See the list of EOC exclusions.

To notify a patient who is already receiving care in a skilled nursing facility that they no longer need skilled nursing care and it will no longer be covered by their plan, skilled nursing facilities (SNFs) may issue the Notice of Medicare Non-coverage form to Medicare Advantage plan members. See details.

Discuss non-coverage with the Medicare Advantage plan member

When an item or service is not specifically excluded from Medicare coverage by the Medicare Advantage plan Evidence of Coverage (EOC) policy document (see a list of EOC exclusions), but you believe it won't be covered by the member's plan:

1. Advise the member:

  • This is a Part C member right; that is, the member has the right to know if something is or isn't covered.
  • CMS wants to be sure Part C plan members know whether they will incur any additional costs other than their plan cost share.

2. Offer to obtain a PSOD.

  • Priority Health will review the member's medical information and CMS rules/regulations to determine coverage and notify both you and the member of our decision.

3. If the member refuses, document the refusal in the medical record. Explain to the member that he or she will have to pay 100% of the cost of any medical services that Medicare doesn't cover.