Medicare Advantage Program Non-Covered Services

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Medicare Advantage Program Non-Covered Services
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November 2015
Medicare Advantage Program
Non-Covered Services
Important Reminder: Florida Blue, as a Medicare Advantage plan with four contracts with the Centers for
Medicare & Medicaid Services (CMS), reminds you that our Medicare Advantage plans must include all
services covered by Original Medicare and must follow Original Medicare’s coverage rules. In general,
Medicare coverage and payment is contingent upon a determination that a service is a covered benefit; a
service is not specifically excluded from coverage; and the item or service is deemed “reasonable and
necessary.”
CMS provides policies and guidance to communicate services considered “non-covered”. The Medicare
Physician Fee Schedule Relative Value file is the primary reference to determine if a specific item or service is
covered. A Status Indicator of “N” reflects non-coverage. Other reference sources in addition to the Medicare
Physician Fee Schedule include: National Coverage Determinations, Local Coverage Determinations, and
National Correct Coding Initiative Policy. Florida Blue will be updating its claim processing system to
better align with these policies and guidance.
Protocol for Non-Covered Services
Florida Blue must issue a determination before you render or refer for the non-covered service or item. If you
know or have reason to believe that a service or item you are providing or referring may not be covered, you
must request a pre-service organization determination from Florida Blue. This request must be initiated prior to
providing or referring for the service or item in order to seek and collect payment from a Medicare Advantage
member for the service or item.
When Florida Blue denies a request for coverage as part of the organization determination, a CMS
standardized denial notice, Notice of Denial of Medical Coverage (or Payment) is issued. You must also obtain
a written acknowledgement from the member indicating they clearly understand the requested service will not
be covered by Florida Blue and that they have agreed to be responsible for the cost of the service. You must
retain this acknowledgement on file.
A pre-service organization determination is not required to collect payment from the member when the
Medicare Advantage Member’s Evidence of Coverage (EOC) or other related materials indicate a service or
item is not covered.
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Member eligibility and benefits can be checked electronically through Availity at Availity.com.
Stay up-to date with the latest Medicare news for Medicare beneficiaries by visiting the CMS website at
www.cms.gov and selecting the Outreach and Education tab.
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Availity, LLC is a multi-payer joint venture company. Visit availity.com to register.
900-1400-1015

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