Medicare HMO denied the claim as covered by hospice

Claims From Medicare Advantage Organizations

Federal regulations require that Medicare fee-for-service contractors maintain payment responsibility for managed care enrollees who elect hospice. These regulations are found that Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.

A - Covered Services

While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS. These claims are subject to the usual Medicare rules of payment, but only for the following services:

1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;

2. Services of the enrollee’s attending physician if the physician is not employed by or under contract to the enrollee’s hospice;

Molina covered Vaccines list

Vaccines for Recipients Birth through (18) Years 

For eligible recipients from birth through (18) years of age, vaccines and combination vaccines providing protection against the following diseases are available free to the VFC-enrolled provider through the VFC program:

  Diphtheria, Tetanus and Pertussis (DTaP)

  Haemophilus Influenzae Type b (HIB)

  Hepatitis B (pediatric and adult)

  Meningococcal Conjugate (MCV4)

  Pneumococcal (PCV 7)

  Polio (IPV)

  Measles, Mumps, and Rubella (MMR)

  Tetanus and Diphtheria (Td) (Adult)

  Influenza

  Varicella

  Human Papillomavirus (HPV)

  Rotavirus

The following vaccines are available by request or for high-risk areas only through the VFC program:

  Hepatitis A

  Diphtheria and Tetanus (DT) (Pediatric)

  Pneumococcal Polysaccharide (PPV)

  Meningococcal Polysaccharide (MPSV4)

Vaccines for Recipients (19) through (20) Years

For eligible recipients ages (19) through (20) years, vaccines and combination vaccines providing protection against the following diseases are reimbursable:

  Hepatitis A

  Hepatitis B

  Human Papillomavirus (HPV)

  Influenza

  Measles, Mumps, and Rubella (MMR)

  Meningococcal Conjugate (MCV 4)

  Meningococcal Polysaccharide (MPSV4)

  Pneumococcal Polysaccharide (PPV)

  Tetanus and Diphtheria (Td)

  Varicella

Process involving change of ownership with Medicare

Provider Change of Ownership

Providers (as defined in 1861(u) of the Act, and institutional suppliers such as RHCs) that undergo a change in their ownership structure are required to notify CMS concerning the identity of the old and new owners.  They are also required to inform CMS on how they will organize the new entity and when the change will take place.  A terminating cost report will be required from the seller owner in all CHOWs for certification purposes.  There are five types of changes that can occur: 

1.   A CHOW in accordance with 42 CFR 489.18; 

2.   Changes in the ownership structure to an existing provider that do not constitute a CHOW;  

3.   A new owner who purchases a participating provider but elects not to accept the automatic assignment of the existing provider agreement, thus avoiding the old owner’s Medicare liabilities; 

4.   An existing provider who acquires another existing provider (acquisition/merger); and  

5.   Two or more existing providers who are totally reorganizing and becoming a new provider (consolidation). 

Providers that undergo a change of ownership will usually continue with the same FI that served the previous owner.  However, if the prospective owner does not wish to accept the automatic assignment of the existing provider agreement, this means that the existing provider agreement is terminated effective with the CHOW date.  The regional office must be notified in writing of the CHOW per instructions contained in section 3210.5 of the State Operations Manual. The prospective owner provides a notice 45 -days in advance of the CHOW to the CMS/RO to allow for the orderly transfer of any beneficiaries that are patients of the provider.  All reasonable steps must be taken to ensure that beneficiaries under the care of the provider are aware of the prospective termination of the agreement.  There may be a period when the facility is not participating and beneficiaries must have sufficient time and opportunity to make other arrangement for care prior to the CHOW date.

Claims Processing Requirements for Medicare Deported Beneficiaries

Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation.  Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit payable under Title II.  Section 1836 of the Act limits Part B benefits to those who are either entitled to Part A benefits or who are age 65 and a United States (U.S.) resident, U.S. citizen, or a lawfully admitted alien residing permanently in the U.S.  Given that, a deported beneficiary is not allowed to enter the U.S. and cannot be lawfully present in the United States to receive Medicare-covered services, Medicare payment cannot be made for Part B Benefits.

An audit of Medicare payments by the Office of Inspector General identified a vulnerability for the Medicare trust fund with respect to this issue.  The study identified improper payments for beneficiaries, who, on the date of service on the claim, had been deported.  To address this vulnerability, CMS is establishing claim level editing using data from the Social Security Administration (SSA).  Specifically, the data contains the name and Health Insurance Claim (HIC) of the Medicare beneficiary and the month the deportation is effective.  CWF will reject claims where the effective date on the Master Beneficiary Record is equal to or greater than the date of service on the claim.  All claims rejected by CWF shall be denied by the respective Carrier, DMERC, RHHI or intermediary that submitted the claim to CWF. 

PSYCHCARE TRIAGE AND REFERRAL PROCESSES

Our  clinical  philosophy  is  to  provide  the  most  appropriate  member/practitioner  match  and  the  least  restrictive treatment intervention for each member's needs across the life cycle. Our clinical orientation is a biopsychosocial approach  with  emphasis  on  wellness,  early  intervention,  and  integration  of  behavioral  and  medical  healthcare. Excellent outcomes are maximized by good partnerships and a clinical consultation approach with all clinicians that deliver services to our members. 

Psychcare  makes  decisions  whether  to  approve  or  not  approve  payment  for  services  based  only  on  the appropriateness of the care or service, and what the member’s benefit plan covers.  

The Medical Director oversees all triage and referral decisions. The Medical Director is available 24 hours per day; 7 days per week, to consult on initial clinical review decisions, and conduct peer clinical review.  

The Vice President of Clinical Operations supervises nonurgent pre-service processes, and initial clinical review processes. The Vice President of Clinical Operations is available 24 hours per day, 7 days per week, to consult with Case Managers on initial clinical review decisions  

Emergency Referrals 

In the event a patient is experiencing a behavioral health emergency in your office, or contacts you in crisis, call the police. If your patient can be safely transported with support, route the member to the nearest emergency room. After ensuring that the patient is safe, call Psychcare 24 hours per day, 7 days a week at (800) 221-5487 so that we can obtain the clinical information and begin managing the case.