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Sunday, April 10, 2011

does precertification required for Medicare advantage plan?

Is a precertification required for a participant enrolled in a Medicare Advantage/Part C Plan?

Inpatient hospital claims for deductible and coinsurance for MO HealthNet patients with Medicare Part C benefits are exempt from admission certification. However, if Medicare Part C benefits have been exhausted and a claim is submitted for MO HealthNet only days, admission certification requirements must be met. Pre-admission certification is required also for denied Medicare Part C inpatient hospital claims including exhausted benefits. Before requesting a pre-certification, the provider must exhaust all appeals through the Medicare Advantage/Part C plan appeals process and have a final denial that can be submitted to Health Care Excel (HCE) with the pre-certification request.

For non-QMB MO HealthNet participants enrolled in a Medicare Advantage/Part C Plan, admissions require certification. Additional information regarding inpatient hospital certification reviews is covered in Section 13.31 of the MO HealthNet hospital provider manual available at www.dss.mo.gov/mhd/providers/index.htm.

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