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Provider Manual

Medicare Advantage Coverage Determination Request

Last Updated on January 24, 2019

Original Medicare ABN requirements do not apply to Medicare Advantage (MA) Program Products

Per Centers for Medicare & Medicaid Services (CMS), Medicare Advantage plans and participating providers may not issue a financial waiver or an Advanced Beneficiary Notice of Non-Coverage (ABN) to any Medicare Advantage member. This applies to all participating providers of Security Health Plan’s Medicare Advantage plans. 

This rule can be reviewed in Chapter 30 of the Medicare Claims processing manual. Per the Medicare ruling, members are allowed an organization determination for services that may not be covered by the plan. Affiliated providers must submit a request for a coverage determination on behalf of the member. The Medicare Advantage Coverage Determination Request can be used to submit a request for an organization determination. This form must be submitted before services are provided. The form can be found in the Provider Document Library.  Security Health Plan has 14 days to provide a determination.

If a coverage determination request is not submitted and services are provided, affiliated providers may be liable for the charges and cannot balance bill the member. If a coverage determination request is submitted and the service is denied, the member will have the right to file an appeal. If, after receiving the denial of coverage information, the service/supply is rendered, the provider should submit a claim for the appropriate denial. 

Claims submitted with a GA modifier will be denied as contractual obligation for invalid modifier.  Contracted providers may not bill a Medicare Advantage member for non-covered services denied to provider responsibility if they have not received an organization determination from Security Health Plan.  Please refer to the appropriate CMS/NGS policy for general Medicare coverage guidelines based on CPT, HCPCS, diagnosis, frequency, etc.  The following is a helpful website for Medicare non-covered services

If you have any questions about this information, please call our customer service line at 1-800-548-1224, Monday - Friday, 8 a.m. - 5 p.m.