This notification is to provide clarification regarding “when it is and when it is not acceptable” to bill Mercy Care Advantage and Mercy Care members for non-covered services.
Under original Medicare CMS permits Medicare participating providers to use an Advanced Beneficiary Notice of Non-Coverage (ABN) for non-covered services. However, CMS prohibits providers contracted with Medicare Advantage plans (like Mercy Care Advantage) to require Medicare Advantage members to sign an ABN to hold the member financially liable for non-covered services.
Under the Medicare Advantage Program requirements, an Advanced Beneficiary Notice of Non-Coverage (ABN) is not a valid form of denial notification for members. Instead contracted providers and/or members must request a pre-service organization determination (OD) to determine if the service requested will be covered or not by their health plan. Organization determination requests must be reviewed by the health plan and if the service is denied, both the member and provider must be notified.
The exception to the process described is when a service is clearly excluded under original Medicare and/or is listed as an exclusion in the Mercy Care Advantage (MCA) Evidence of Coverage and/or the member elects to receive the denied service, instead of exercising their Medicare appeal rights.
In this type of situation, the contracted provider must educate the member that the service is NOT covered by Medicare or MCA and they will be held financially responsible. Prior to providing the non-covered service, the provider office should have the member sign a document (not an ABN) documenting the service requested by the member and the date the member education was provided to the member acknowledging financial responsibility. This document should be retained in the members records in the event the member seeks reimbursement from the health plan and the health plan reaches out to the provider office for information about why the member paid for the service.
AHCCCS generally prohibits AHCCCS-registered providers from billing Medicaid members and can impose a penalty for inappropriate billing of a AHCCCS eligible members.
Detailed information is available at
Arizona Revised Statute §36-2903.01(K) prohibits providers from billing AHCCCS members, including QMB Only members, for AHCCCS-covered services.
Upon oral or written notice from the patient, that the patient believes the claims to be covered by the system [AHCCCS], a provider or non-provider of health and medical services prescribed in §36-2907 shall not do either of the following unless the provider or non-provider has verified through the Administration that the person has been determined ineligible, has not yet been determined eligible, or was not, at the time services were rendered, eligible or enrolled:
- Charge, submit a claim to, and/or demand or otherwise collect payment from a member or person who has been determined eligible, unless specifically authorized by this article or rules adopted pursuant to this article.
- Refer or report a member or person, who has been determined eligible, to a collection agency or credit reporting agency for the failure of the member or person, who has been determined eligible, to pay charges for system covered care or services, unless specifically authorized by this article or rules adopted pursuant to this article.
The exceptions to the above are found in
, which outlines the situations when it would be appropriate for an AHCCCS-registered provider to bill a member.
Registered providers must accept payment from the Administration (AHCCCS) or a contractor (Mercy Care) as payment in full except, except in the situations described below:
An AHCCCS registered provider may charge, submit a claim to, or demand or collect payment from a member:
- To collect the copayment described in R9-22-711;
- To recover from a member that portion of a payment made by a third party to the member for an AHCCCS covered service if the member has not transferred the payment to the Administration or the contractor as required by the statutory assignment of rights to AHCCCS;
- To obtain payment from a member for medical expenses incurred during a period when the member intentionally withheld information or intentionally provided inaccurate information pertaining to the member’s AHCCCS eligibility or enrollment that caused payment to the provider to be reduced or denied;
- For a service that is excluded by statute or rule, or provided in an amount that exceeds a limitation in statute or rule, if the member signs a document in advance of receiving the service stating that the member understands the service is excluded or is subject to a limit and that the member will be financially responsible for payment for the excluded service or for the services in excess of the limit;
- When the contractor or the Administration has denied authorization for a service if the member signs a document in advance of receiving the service stating that the member understands that authorization has been denied and that the member will be financially responsible for payment for the service;
- For services requested for a member enrolled with a contractor, and rendered by a non-contracting provider under circumstances where the member’s contractor is not responsible for payment of “out of network” services under R9-22-705(A), if the member signs a document in advance of receiving the service stating that the member understands the provider is out of network, that the member’s contractor is not responsible for payment, and that the member will be financially responsible for payment for the excluded service;
- For services rendered to a person eligible for the FESP if the provider submits a claim to the Administration in the reasonable belief that the service is for treatment of an emergency medical condition and the Administration denies the claim because the service does not meet the criteria of R9-22-217; or
- If the provider has received verification from the Administration that the person was not an eligible person on the date of service.
As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our
Mercy Care website
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