APMA News - September/October 2020 - 18

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payment policies apply, may mean that the service was covered under the plan, but the plan's payment policies resulted
in non-payment under the circumstances.

Contracted Providers
Medicare law addresses neither the manner in which an
MA organization must pay a contracting provider for furnishing covered services nor the amount it must pay. Thus,
the requirement to cover the same services under original
Medicare does not mean that plans must pay their contracting providers in the same manner and amount as original
Medicare. Payment arrangements are considered a private
contractual matter between the provider and the MA organization. MA organizations are free to adopt their own
coding and editing policies consistent with the payment
terms set forth in their contracts with providers or set forth
in their policies and procedures, which are incorporated by
reference into their provider contracts. Therefore, an MA
plan may "cover" a service covered under original Medicare
without paying for it in the same manner as original Medicare. For example, under the MA organization's payment
policies, payment for the service may be bundled with other services and no separate payment is made for that
service. The service is "covered" in compliance with the
Medicare requirements in instances in which members
have access to the service when it is medically necessary
and pay no more than the member cost-sharing set forth in
their evidence of coverage for the service. The EOB for an
item or service should indicate the reason for denial or reduction of payment.

Non-Contracted Providers
MA law does specifically address and specify the amount of
payment to providers who provide covered services to
members but do not have written contracts with the MA
plan. This law includes providers who furnish emergency or
out-of-area urgently needed services to MA members, as
well as non-contracted providers who furnish services to a
member of an MA PPO.
Medicare law requires that MA plans pay these providers
the same amount that they would have received under original Medicare for furnishing covered service to their members. Thus, for these providers, the plans must follow the
coding policies-including recognition of modifiers-of
original Medicare.

Appeals
If a physician wishes to appeal a decision that a service is not
a covered service or to appeal a payment amount that is different from what original Medicare would have paid (in instances in which the physician is entitled to be paid the same
amount as original Medicare), the physician should include
with the appeal request EOBs from original Medicare for the
same services that evidence the original Medicare coverage or
18 APMA News September/October 2020

payment amounts. The physician should de-identify these
EOBs to make them HIPAA-compliant.
Specific appeal procedures and rights vary regarding the
matter at issue and whether a physician is contracting or
non-contracting with the MA plan. Note that the appeal process discussed below is the process for medical benefits, including Part B drugs. There is a separate process for appeals
related to Part D drugs/benefits.

Contracted Providers
The appeal process for contracted providers depends on
whether the appeal is made prior to furnishing the service
(i.e., to appeal a denied request for prior authorization) or after furnishing the service (i.e., to appeal a claim for payment
denied in whole or part or paid at a lower amount than the
physician believes they are entitled to).

Claims Appeals
MA law and policy do not prescribe an appeal process for
contracting providers who have had claims for payment denied in situations in which the patient is held harmless.
Such appeals are a matter of contract negotiations or the
health plan's policies and procedures. Thus, contracting
providers looking to appeal a denied claim should look to
their contracts or the organization's policies and procedures
to determine their appeal rights. Such rights and procedures
vary by organization.
Non-contracted providers who wish to appeal a payment
denial or the amount of payment should first refer to the payment terms in their written agreement to determine whether
the plan has paid them in a manner and amount consistent
with the terms of the agreement. Many MA plan contracts
include references to payment rates under original Medicare
(e.g., stating that the plan will pay 100 percent of the Medicare allowable rate for covered services). If an agreement includes such a reference, the provider should carefully check
the wording to determine if the plan has contractually obligated itself to pay the same amounts as original Medicare
would pay. If so, there is a good argument that the plan
should follow the coding policies under original Medicare.

Pre-Service Appeals
MA law includes a specific process for member appeals (referred to under MA law as "reconsiderations"). Except in the
case of a pre-service appeal, a contracting provider may not
use this process to appeal on behalf of a member, even via an
appointment of representative form.
For standard pre-service appeals, a physician who is providing treatment to an MA member may request a standard
reconsideration on the member's behalf. Such appeals must
be requested within 60 days of the date of the adverse decision. The health plan generally has 30 days to make a decision. If it upholds its previous denial or fails to provide a decision in that timeframe, the plan must automatically forward
the case file to an independent review entity (IRE) contracted

APMA News - September/October 2020

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