CMS guidance states that providers cannot charge Peoples Health patients for noncovered services beyond applicable copayments, coinsurance or deductibles, unless the patient received a Notice of Denial of Medical Coverage before the services were provided and still chose to receive the noncovered services, or via a clear exclusion in the Evidence of Coverage.
If you believe that a service may not be covered, or could be covered only under specific conditions, you can request an organization determination on the patient’s behalf or direct the patient to request one. To request it on the patient’s behalf, submit a medical necessity request via the Provider Portal. You must upload all appropriate attachments, such as physician orders or supporting documentation, with your request.
You may not give the patient an Advance Beneficiary Notice of Noncoverage (ABN). The ABN is only given to beneficiaries enrolled in the Medicare fee-for-service program. It is not used for items or services provided under a Medicare Advantage plan. Patients in these plans always have the right, prior to receiving services, to an organization determination of whether the services are covered.