Medicare - Administrative Procedures |
Billing of Members
Copayments:
Participating providers are required to collect copayments from members for services performed in the office setting for which the provider submits a claim. (The copayment amount/applicable services, as stated on the ID card, are governed by the member’s Evidence of Coverage or other legal documents, as applicable.) Services that require a copayment include, but are not limited to, office visits, pain management services, and diagnostic/therapeutic procedures.
Some examples of services that generally do not take a copayment are as follows:
• care related to pregnancy, after the initial office visit copayment is made;
• certain antepartum care: amniocentesis, biophysical profile, fetal ultrasound exam- inations, and fetal stress/non-stress test;
• chemotherapy administration services, billed as a single service and not part of an office visit;
• immunization codes;
• laboratory codes and/or venipuncture, if no other service is billed; and
• mammography screening.
Note: In any case, the member is only responsible
for one copayment per day, per billing provider/group in the same specialty, for
applicable services provided. For example, when physicians bill for a preventive
visit in addition to an office visit, on the same date of service, only one
copayment should be collected.
Coinsurance:
ConnectiCare offers plans that have coinsurance requirements. To ensure a more effi- cient billing process, bill ConnectiCare for services rendered prior to taking any cost- sharing payments from members. This will allow you to verify whether the member has coinsurance requirements. When you receive your remittance from us, you may then bill the member for the portion of the bill for which he/she is responsible, as indicated on the EOP.
Covered Services:
Participating providers may not bill members for any service that is covered under the member’s ConnectiCare plan. Nothing in this section is intended to restrict or prohibit providers from billing a member for any applicable copayment, coinsurance, or deductible for certain covered services, as required under the member’s Plan.
Denied Services:
Members should not receive a statement or be billed, unless the service has been denied with an explanation code that allows the member to be billed. If you’re not sure of whether member liability exists, contact Provider Services before billing a member.
Note: Prior to initiating services that are not covered under a member’s plan, the physician or other health care provider must advise the member that the service is not covered, that the member will be held responsible for the associated costs, and the member must agree to be financially liable for those costs prior to receiving the services.
Refunds/Overpayments by Members:
If you receive an overpayment from a member that exceeds the cost share for which they are responsible according to their benefit plan, we request that you refund the appropriate amount back to the member in a timely manner. You can verify whether or not a member is due a refund by referring to your Explanation of Payment and reconciling it against your patient accounts.
Advance Beneficiary Notice:
If a member is told a service is not covered and they agree to pay out-of-pocket, then the provider can bill the member if they have signed a beneficiary notice form in advance of those services.
