Providers Not Participating with Medicare
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Governs payment and billing requirements for providers who are not in the Aspirus Health Plan Medicare Advantage network and their reimbursement when they participate, do not participate, or opt out of Original Medicare. Applies to Aspirus Health Plan Medicare Advantage members and relevant providers.
Establishing annual review cadence.
A clarification was made to the definition section of this policy.
Aspirus establishes written policy for Providers Not Participating with Original Medicare.
Payment Determinations by Provider Medicare Participation
Payment scenarios by Original Medicare participation status
Payment determination for covered services when provider is not in Aspirus Medicare Advantage network:
ALL of the following
- Reimburse at the Original Medicare participating allowed amount based on provider geographic location (less member cost-share).
Provider may bill member for cost-share but may not bill member for the difference between their charge and the Aspirus Health Plan allowed amount.
ALL of the following
- Reimburse at 100% of the Original Medicare allowed amount (Medicare guidance indicates minimum 95%) based on provider geographic location (less member cost-share).
Provider may bill member for cost-share but may not bill member for the difference between their charge and the Aspirus Health Plan allowed amount.
ALL of the following
- Reimburse at 100% of the Original Medicare allowed amount (Medicare guidance indicates minimum 95%) based on provider geographic location (less member cost-share).
A Medicare non-participating provider is limited to charging no more than the limiting charge for the service; the provider may bill the member for cost-share and the difference between the limiting charge and the Aspirus Health Plan allowed amount.
- For DMEPOS/DMEPEN services where CMS has not developed limiting charges, the provider's charge replaces the limiting charge for reimbursement determinations.
ALL of the following
- Providers who have opted out are not entitled to payment from Aspirus Health Plan and claims will be denied except for emergency or urgent services per Medicare guidance.
ALL of the following
- Covered services rendered by a provider practicing under a Critical Access Hospital Method II are reimbursed at the lesser of the billed charge or 115% of the Medicare Professional Fee Schedule.
- When a Method II practitioner does not participate with Original Medicare and is non-participating with Aspirus, the AK modifier must be used and reimbursement is 100% of the Original Medicare allowed amount (minimum 95%) based on geographic location (less member cost-share).
Payment calculation example: ((Facility MPFS * .95) - Member Cost Share) * 1.15.
Provider participation and reimbursement criteria
Rules for reimbursement and billing depending on provider participation status and service type.
ALL of the following
- Reimbursed at 100% of the Original Medicare allowed amount (Medicare guidance indicates minimum 95%), less member cost-share.
- Provider may bill member for any cost-share amount owed but may not bill the member for the difference between their charge and the Aspirus Health Plan allowed amount.
ALL of the following
- Reimbursed at 100% of the Original Medicare allowed amount (Medicare guidance indicates minimum 95%), less member cost-share.
- Provider may bill member for cost-share and for the difference between the limiting charge and the Aspirus Health Plan allowed amount; non-participating providers are limited to charging no more than the limiting charge.
ALL of the following
- CMS has not developed limiting charge amounts for DMEPOS or DMEPEN; accordingly, the provider's charge replaces the limiting charge for reimbursement determinations.
ALL of the following
- Covered services reimbursed at the lesser of billed charge or 115% of the Medicare Professional Fee Schedule.
- When a Method II practitioner is non-participating with Original Medicare, the AK modifier must be used; reimbursement will be 100% of the Original Medicare allowed amount (minimum 95%), less member cost-share.
- Payment calculation example provided: ((Facility MPFS * .95) - Member Cost Share) * 1.15.
ALL of the following
- Opt-out providers cannot participate in Medicare programs and are not entitled to payment from Aspirus Health Plan; claims will be denied except for emergency or urgent services.
- For emergency or urgent services furnished by an opt-out provider, the provider may bill Aspirus Health Plan on behalf of the member, must not charge the beneficiary more than the limiting charge, and must append the -GJ modifier to each claim line to attest services were emergency/urgent; missing -GJ or existence of a private contract results in denial.
- Claims for eligible emergency/urgent services from opt-out providers will be processed as if the provider is non-participating and reimbursed at 100% (minimum 95%) of the Original Medicare allowed amount (less member cost-share).
ALL of the following
- Aspirus follows Original Medicare pricing guidelines; reimbursed amounts must be no less than Original Medicare and providers must accept that amount as payment in full; balance billing must follow Original Medicare rules.
ALL of the following
- Providers are required to submit claims on behalf of Aspirus Health Plan members.
ALL of the following
- Aspirus will follow Medicare guidance for geographic and regulatory pricing adjustments, claim edits and processing rules including NCCI/PTP/MUE edits, add-on and facility adjustments, global surgical package definitions, surgical reductions (including bilateral), modifier effects, NCD/LCD criteria, and provider-type decreases where applicable.
ALL of the following
- The most current prior authorization, notification, and threshold requirements are maintained on the plan website and updated from time to time; providers should consult the plan website for current requirements.
Codes, Modifiers, and Claim Edits
| No codes listed |
| AK | Non Participating Physician (Critical Access Method II) |
| GJ | 'Opt-Out' Practitioner, Emergency or Urgent Services |
| NCCI | National Correct Coding Initiative edits apply |
| PTP | Procedure to Procedure edits apply |
| MUE | Medically Unlikely Edits apply |
| Add-on Code Edits | Add-on Code Edits apply |
| Facility Edits | Facility Edits apply |
Billing, Modifier and Authorization Requirements for Providers
Provider billing and modifier requirements — determine payment based on provider's Original Medicare participation status; use AK modifier for non-participating CAH Method II practitioners; -GJ for opt-out emergency attestation (billing risk/highlight)
Aspirus Health Plan follows Original Medicare guidance for providers who do not participate in the Aspirus Health Plan Medicare Advantage network(s). Aspirus Health Plan is required to reimburse these providers for covered services provided to Aspirus Health Plan Medicare Advantage members at an amount that is no less than the amount that would be reimbursed under Original Medicare. Aspirus Health Plan expects providers to follow Medicare requirements regarding balance billing. Aspirus Health Plan takes into consideration the provider's participation status with Original Medicare when determining payment for professional claims. When a provider does not participate in the Aspirus Health Plan Medicare Advantage network(s), total reimbursement will be determined based on the provider's status with Original Medicare under the following scenarios: (1) Provider participates with Original Medicare; (2) Provider does not participate with Original Medicare but accepted assignment; (3) Provider does not participate with Original Medicare and did not accept assignment; or (4) Provider has opted-out of Original Medicare. Listed below is information explaining Aspirus Health Plan pricing and the source documents used to define how Aspirus Health Plan allowed amounts are determined.
- Professional claims: Providers who do not participate in the Aspirus Health Plan Medicare Advantage network(s) but have elected to participate with Original Medicare will be reimbursed at the Original Medicare participating allowed amount based on the geographic location of the provider (less the member cost-share). Providers may bill members for cost-share amounts but may not balance bill the difference between their charge and Aspirus Health Plan allowed amount.
- Providers who do not participate in the Aspirus Health Plan Medicare Advantage network(s) and do not participate with Original Medicare but are accepting assignment will be reimbursed at 100% (Medicare guidance indicates a minimum reimbursement of 95%) of the Original Medicare allowed amount based on geographic location (less member cost-share). Non‑participating providers who accept assignment are limited by the Medicare limiting charge and may bill members for cost-share amounts but not the difference between their charge and Aspirus Health Plan allowed amount.
- Providers who do not participate in the Aspirus Health Plan Medicare Advantage network(s) and do not participate with Original Medicare and are not accepting assignment will be reimbursed at 100% (Medicare guidance indicates a minimum reimbursement of 95%) of the Original Medicare allowed amount based on geographic location (less member cost-share). These non‑participating providers are limited by the Medicare limiting charge; they may bill the member for cost-share and the difference between the limiting charge and Aspirus Health Plan allowed amount.
- DMEPOS & DMEPEN: The same guidelines associated with professional services apply. CMS has not developed limiting charge amounts for DMEPOS or DMEPEN services; accordingly, the provider's charge will replace the limiting charge amount for DME.
- CAH Method II: Practitioners who have reassigned billing rights to the CAH are reimbursed at the lesser of billed charge or 115% of the Medicare Professional Fee Schedule. When a Method II practitioner does not participate in the Aspirus Health Plan Medicare Advantage network(s) and does not participate with Original Medicare, use modifier AK (Non‑Participating CAH Method II Practitioner). These providers will be reimbursed at 100% (Medicare guidance indicates a minimum reimbursement of 95%) of the Original Medicare allowed amount (less member cost-share). Example payment calculation: ((Facility MPFS * 0.95) - Member Cost Share) * 1.15. Method II providers may bill members for cost-share but may not bill the member for the difference between their charge and the Aspirus Health Plan allowed amount.
- Opt‑out of Original Medicare: Providers who have formally opted out of Original Medicare are subject to opt‑out rules. Aspirus Health Plan will determine reimbursement consistent with Medicare opt‑out guidance; such providers should not balance bill beyond what opt‑out rules permit.
Prior Authorization Updates
Aspirus Health Plan updates prior authorization, notification, and threshold requirements from time to time. Providers are responsible for verifying the most current prior authorization and notification requirements before delivering services. Failure to obtain required prior authorization or to follow current notification/threshold rules may result in claim denial or member liability.
- Check the Aspirus Health Plan provider portal or prior authorization resources for the most current requirements and any changes to thresholds, notification processes, or covered codes.
- When in doubt, obtain prior authorization or required notifications in advance and retain documentation of approvals and communications to support claims.
- Providers billing for services subject to changing authorization rules should note the effective date of any authorization and ensure the member’s plan and service date fall within approved authorization windows.
Definitions and Modifier Meanings
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