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Provider Manual

Medicare Advantage Coverage Inquiry for Organization Determination Process

Last Updated on November 30, 2018

On May 5, 2014 The Centers for Medicare & Medicaid Services (CMS) ruled that Medicare Advantage plans and their contracted providers may not issue a financial waiver or an Advanced Beneficiary Notice of Non-Coverage (ABN) to any Medicare Advantage member as an appropriate notification of non-coverage. Security Health Plan’s Medicare Advantage plans include Medicare Advantage Core-Southern, Eastern and Ally Rx (DSNP). This rule can be found in the Medicare Managed Care Manual, Chapter 4, Section 160: Beneficiary Protections Related to Plan-Directed Care.

Instead of an ABN, Security Health Plan’s contracted providers are required to submit a Medicare Advantage Coverage Inquiry on behalf of a member. Please see the Frequently Asked Questions below for information on when a Coverage Inquiry is required. Once Security Health Plan receives the Coverage Inquiry, a coverage decision will be made and appropriate notification will be sent to both the provider and member. If a Coverage Inquiry is not submitted and the services do not meet Medicare criteria, the claim will be denied as provider responsibility and services cannot be billed to the member.  

Non-contracted providers are not required to follow this process and may continue to issue ABNs or submit a Coverage Inquiry if preferred. If an ABN is utilized the GA modifier must be submitted on the claim to indicate the ABN was issued and is on file. Providers do not need to submit a copy of the ABN, but must have it available upon request. If a Coverage Inquiry is on file or the service is submitted with the GA modifier items not covered will be denied member responsibility.

Providers can follow these steps to submit a Coverage Inquiry:

  1. Electronically via the Security Health Plan Provider Portal
  2. By mail or fax – print the Medicare Advantage Coverage Inquiry
    1. Fax to 715-221-6616
    2. Mail:

      Security Health Plan
      1515 St. Joseph’s Ave
      PO BOX 8000
      Marshfield, WI 54449

  3. Security Health Plan will review the  Coverage Inquiry and issue an Organization Determination to the member and the provider
  4. If the service does not require an Organization Determination, Security Health Plan will respond only to the provider stating that an Organization Determination is not required for this service.

Frequently Asked Questions

When is an Organization Determination needed?

An Organization Determination is needed only when the service being requested is sometimes covered by Medicare based on medical necessity requirements and you do not feel the member will meet criteria.  Obtaining an organization determination via the Coverage Inquiry will allow you to bill the member for services denied by Security Health Plan as patient responsibility.  If you do not obtain an organization determination and the services provided do not meet the established criteria for coverage, Security Health Plan will deny as provider responsibility.

When is an Organization Determination NOT needed?

  1. The service is sometimes covered based on criteria, and the member meets the criteria to have the service covered
  2. If the service being requested is a Medicare Statutory Exclusion
  3. If a service is always covered by Medicare
  4. If a service is excluded as outlined in Security Health Plan’s Evidence of Coverage

When should an Organization Determination be expedited?

An organization determination should be expedited only if waiting for the decision under standard response time could place the member’s life, health, or ability to retain maximum function in serious jeopardy.  In these instances an organization determination can be requested after a member has received the service. 

What if the member wants a service that is not covered?

If a service is never covered by Medicare (a Medicare Statutory Exclusion) and the member still wants the service, you can provide the service and bill the member directly for the service.   It would be to the provider’s and member’s benefit to notify the member of non-coverage and have written confirmation of that notification. 

Can we still utilize the GA modifier?

Security Health Plan will follow CMS guidelines and claims submitted with a GA modifier for contracted providers will be denied as a contractual obligation for invalid modifier.

What if the service requires prior authorization through Security Health Plan?

If the service you are providing requires prior authorization through Security Health Plan, you do not need to submit a Coverage Inquiry for an Organization Determination in addition to the prior authorization request. Only the prior authorization request is required.

Provider Resources:

CMS Memo dated May 5, 2014 

Security Health Plan Provider Relations and Contracting at (715) 221-9640.