Wednesday, July 13, 2016

Medicare rejection CO 24 - covered by Advantage plan

 We received a RUC for the claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?

Charges are covered under a capitation agreement/managed care plan.

A: You are receiving this reason code due to the beneficiary being enrolled in a Medicare Advantage (MA) plan or covered under a capitation agreement.

Medicare Advantage (MA):

• If a Medicare beneficiary enrolls into a Medicare Advantage plan, that health plan will then replace the beneficiary’s traditional Medicare plan.

• Medicare claims must be submitted to the MA plan.

• If a claim is submitted to Medicare it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate this claim adjustment reason code CO24.

• Obtain eligibility and benefit information prior to rendering services to patients.

• Ask patients if they have recently enrolled in any new health insurance plans.

• Request to see a copy of all of their health insurance cards.

• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.

• Click here for ways to verify the beneficiary's eligibility prior to submitting claims to First Coast.
• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).

• Claims that are returned as unprocessable cannot be appealed, for more information click here.
End-stage renal disease (ESRD) capitation agreement:

• Prior to seeing a patient for ESRD related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.

• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines external link and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.

Medicare replacement FAQ

Q: For a patient not enrolled in traditional Medicare Part B but enrolled in a Medicare replacement, can a participating Part B provider ask for payment at the time of service (at the standard Medicare fee schedule rate) and instruct the patient to file the claim with the Medicare replacement for direct reimbursement? Regarding traditional Medicare vs. Medicare Advantage (MA) plans, what fee schedule can we bill?

A: If the patient is enrolled in a Medicare Advantage (MA) plan, contact the MA prior to rendering services to determine what amount he or she is responsible for paying out of pocket. This information will provide you with guidance on whether to treat and/or bill the patient. Medicare does, however, limit the amount providers can bill patients for services. For more information, please refer to Medicare & You 2018 external pdf file.

When a patient enrolled in a MA plan uses out-of-network providers, their out of pocket expenses for covered services may be higher. It is important to verify with the patient [and confirm through First Coast’s Part B Interactive Voice Response (IVR) system at 1-877-847-4992 or through SPOT (Secure Provider Online Tool)] if the patient is enrolled in an MA.

The Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Publication 100-16, Services of non-contracting providers and suppliers, Chapter 4 - Benefits and Beneficiary Protections external pdf file states:

• MA plans must reimburse non-participating providers for emergency care, ambulance services sought through 911 calls, and for medically necessary dialysis services from a non-participating provider when the patient is out of the service area.

The CMS IOM Publication 100-16, Services of non-contracting providers and suppliers, Chapter 6 - Relationships with Providers external pdf file further states:
• Non contracted providers must accept as payment in full no amount greater than what original Medicare would pay and cannot bill the patient more than their normal cost-sharing amounts (coinsurance).

There are numerous potential scenarios and the answer may change dependent upon terms of the plan. In general, if an MA enrollee seeks care outside of the MA plan in which he/she is enrolled and the Medicare Advantage organization (MAO) sponsoring the MA plan has no legal liability for reimbursement, then yes, the provider can bill the MA enrollee. The provider should not bill the MA enrollee more than the original Medicare amount for what would otherwise be covered A/B services.
There is no specific guidance for collecting payment from the patient at the time services are rendered.

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