Advance Beneficiary Notices Disallowed in Billing Noncovered Services for Blue Medicare

CMS issued guidance regarding the Medicare Advantage program that affects Blue Cross and Blue Shield of North Carolina’s (BCBSNC’s) Medicare provider agreements (CMS memo Improper Use of Advance Notices of Non-Coverage).  CMS’s guidance addresses what a provider must do in order to charge a member on a Medicare Advantage health plan for services that are not covered by the member’s benefits coverage policy. Prior to this clarification, Medicare Advantage members were often billed for noncovered services when a provider of noncovered services obtained a detailed waiver or an Advance Beneficiary Notice-like document from the member before the noncovered services were provided.  However, CMS has now stated that providers may not use this waiver process with members of Medicare Advantage plans; instead, they must ensure that the beneficiary has received a pre-service organization determination regarding coverage before the provider can bill the beneficiary for noncovered services. As a result, providers must refrain from charging any member on a BCBSNC Medicare Advantage plan for any noncovered services, including services that were provided under a previously-executed waiver, unless that member has received a pre-service organization determination from BCBSNC.