Frequently Asked Questions: Medicare Advantage
(Part C) Pre-Service Organization Determinations
This information is current as of 11/16/2015. See the Priority Health Provider Manual Notice of
Medicare Part C non-coverage page for the most current information.
The Centers for Medicare and Medicare Services (CMS) established a Part C or Medicare Advantage
(MA) rule about proper notice of non-coverage to MA members, including that utilizing an Advance
Beneficiary Notice (ABN) is no longer allowed. Unlike fee-for-service (FFS) Medicare (or Original
Medicare), only a Part C or MA plan can issue a notice of non-coverage, not a provider. This rule can be
found in the Medicare Managed Care Manual, Chapter 4, Section 170: Beneficiary Protections Related to
Plan-Directed Care. This rule applies to all Part C Medicare Advantage plans.
Here we answer some of the frequently asked questions about what Priority Health Medicare contracted
providers should do when providing non-covered services.
Q:
What is an “appropriate notice of non-coverage”?
A:
Appropriate notice of non-coverage can only be made by Priority Health through one of two ways:
 A Notice of Denial of Medicare Coverage (or Payment)/CMS-10003 issued by Priority Health
OR
 A clear exclusion in the member’s Explanation of Coverage (EOC)
Q:
Can I still use an ABN or ABN-like form?
A:
No, ABNs and ABN-like forms can’t be used with Priority Health Medicare members. ABNs can
only be used with FFS Medicare beneficiaries. Our members are Part C Medicare beneficiaries.
Q:
What will happen if I use an ABN or ABN-like form?
A:
Use of these forms on or after 12/7/15 means your claim may go to provider liability.
Q:
What does this mean?
A:
Providers who do not obtain a pre-service decision, known as an organization determination, for
services that are not covered by Priority Health will have their claims denied for provider liability
and you will not be able to bill the member for any portion of a denied claim.
Q:
Is this unique to Priority Health?
A:
No, all insurance companies must implement a process for providing pre-service determinations of
coverage. Many national insurance companies have already implemented a process similar to
ours, whereas others have simply aligned with all Medicare benefits, and other plans are still
researching their appropriate solutions.
Q:
When do I request a pre-service “organization determination”?
A:
Prior to rendering a service, you must determine whether or not an item or service is covered by
your patient’s Medicare Advantage plan. You can use a medical necessity software checker or the
Edits Checker tool on priorityhealth.com.
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If the software indicates the service is denied due to a Medicare exclusion, check the
member’s EOC to identify if there is a “clear exclusion” for the item or service.
If the software indicates the service may be denied due to Medicare medical policy or lack
thereof, notify the member and request a pre-service organization determination.
NOTE: Priority Health Medicare plans must cover everything Medicare Part A and Part B covers.
Q:
What happens if I don’t tell the member that something is not covered?
A:
Providers who don’t follow one of the steps identified above prior to rendering a service will have
their claims denied for provider liability. They will not be able to bill the member for any portion of a
denied claim.
Q:
How do I request a proper Priority Health Medicare notice of non-coverage?
A:
For services not excluded by the member’s EOC, complete the Medical Prior Authorization form,
check the “pre-service organization determination” box and fax it to 888.647.6152.
Q:
What if I have a question? What are the hours I can call?
A:
Call the Provider Helpline at 800.942.4765 Monday through Thursday from 8:30 a.m. until 5 p.m.,
and on Fridays from 9 a.m. until 5 p.m. The member call center is open seven days a week.
Q:
How long does it take to get the notice of non-coverage from Priority Health?
A:
Under CMS rules, Priority Health has 14 calendar days from the time we receive a request to make
a standard decision and notify the member and provider. Priority Health may also extend this time
frame for up to an additional 14 calendar days if we haven’t been able to obtain the necessary
information to make a decision. Priority Health will issue a letter whenever an extension is being
made. For more information about standard organization determinations see the Medicare
Managed Care Manual, Chapter 13.
Q:
What if I need a decision “faster” than that?
A:
You may request a fast or “expedited” organization determination decision if you believe waiting for
a decision under the standard time frames could place your patient’s life, health or ability to regain
maximum function in serious jeopardy. Requests for expedited organization determinations require
submission of medical records at time of the request. For more information about expedited
organization determinations see the Medicare Managed Care Manual, Chapter 13.
Q:
How long does it take to make a fast organization determination?
A:
Priority Health has 72 hours from time we get the request to make a fast decision. The member
must be notified orally as well as receive a written notification within 72 hours.
Q:
What if Priority Health denies the request for a fast organization determination?
A:
We automatically transfer the request to the standard time frame and make the decision within 14
calendar days of the date we received the request for the expedited determination. We notify both
the member and the provider verbally and send a letter to them within three calendar days of the
denial.
Q:
Can I provide a non-covered service excluded by the member’s EOC without calling Priority
Health?
A:
Yes, if there is “clear” exclusion in the member’s EOC you may provide the service but Priority
Health requires that you inform the member of the “clear” exclusion and document that in their
record. You can also have the member sign a form stating that they understand they are liable for
any costs (this will be available in the Provider Manual soon). You may not use any ABN-like form
to complete this requirement.
Q:
What happens if I’ve provided the service and told the member the service was not covered?
A:
Even though you “told” the member, if there is no clear exclusion in the member’s EOC, CMS rules
require that Priority Health inform the member of non-coverage. Without proper notice of noncoverage, your claim will be denied and the member cannot be billed for the service.
Q:
Can I ask for a prior auth if I’ve already performed the service?
A:
No. Under Part C rules, once a service has been performed, a request for the service is considered
a request for payment.
Q:
How do I bill to show appropriate notice of non-coverage?
A:
Providers must bill Priority Health for any service, whether covered or not, provided to a Priority
Health Medicare member. In billing for non-covered services, providers can demonstrate they
obtained an appropriate notice of non-coverage outlined below by using one of the following
modifiers:
 GA modifier: Use the GA modifier to show that appropriate notice of non-coverage (CMS-10003)
was given. Providers do not need to submit this notice with their claims. However, if the member
appeals a claim associated with a GA modifier and there is no proof that the provider obtained the
appropriate notice of non-coverage, the claim will be reversed to provider liability.
 GY modifier: Use the GY modifier to show that the service or item was clearly excluded under
the member’s Priority Health EOC. However, if the member appeals any claim associated with a
GY modifier and either there is no exclusion in the EOC or the exclusion is “not clear,” the claim
will be reversed to provider liability. You can also use the GY modifier if the member refused to
wait to receive an organization determination in favor of having the service completed
immediately.
Q:
Can I appeal a denial of a pre-service organization determination?
A:
CMS grants contracted providers the ability to appeal a denial on behalf of the member in two
situations: (1) For standard pre-service reconsiderations or appeals, a physician who is providing
treatment to a member may, upon providing notice to the member, request a standard
reconsideration or appeal on the member’s behalf without submitting proof that the physician is the
member’s personal representative; or (2) For expedited reconsiderations.
This information is a summary. Please refer to CMS regulations and the Priority Health Provider Center
for more details.