New CMS requirement for non-covered services/supplies

In accordance to notification from CMS, the Advanced Beneficiary Notice (ABN) used in the original Medicare program is not applicable to Medicare Advantage programs. Therefore, when informing a BlueAdvantage member that a service is not covered or is excluded from their health benefit plan, the decision is considered an organization determination under 42 CFR, 422.566(b) and requires the appropriate CMS notice of denial of coverage (CMS-10003). A “waiver” is no longer sufficient documentation of this notification. BlueChoice HMO or BlueAdvantage Plan network providers should request a pre-determination from BlueAdvantage on the member’s behalf before any non-covered service/supply is provided.