The topic of deluxe features is likely addressed within the bylines of your contract with the payer, or is embedded in online provider manuals and instructions. The first task is to discern the payer’s policy as it relates to deluxe items and how they should be billed. In some cases, providers are instructed to bill an added line as a non-covered service. Others instruct to append certain modifiers. Begin your search for the term “deluxe” while surfing online versions of provider manuals. If you do not find a clear directive, reach out to a provider services representative. This may not be a question they are used to receiving, so be sure to press for an answer that they can put in writing to you.
The other relevant instruction you need to seek guidance on is transferring liability when the beneficiary does not meet coverage guidelines. Historically, HMOs have not accepted Medicare ABN forms, but up until the last few years, many used a variation of the form to pass financial liability to the beneficiary for certain non-covered products. However, in May of 2014, CMS issued a cease order to all Medicare Advantage Plans to immediately stop accepting notices modeled after the Medicare ABN. One such letter was posted to the UHC website.
On the heels of this letter, plans such as United Healthcare began to comply with CMS directives. The UHC protocol is outlined on their website. UHC (like many others) is utilizing a prior-authorization type determination system. Once the request is submitted by the supplier to UHC, and the service is deemed to be non-covered, an Integrated Denial Notice (IDN) will be sent via mail to both the supplier and the plan member. The supplier can only render the non-covered service after the IDN has been received.
As your business model evolves, and as you begin to explore alternative options permitted by your plans, you will need to secure answers to questions like the ones posed here. These answers allow you to evaluate your options, move forward compliantly and service your customers with confidence.
We’ll be answering more ABN related questions and concepts during our event on October 27. If you have an ABN confidence problem, let us give you a necessary boost as we dive in to The ABN: Getting It "Just Right.”