ModifiedAspirus ArisePolicy AS24P0003A1

Providers Not Participating with Medicare

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.

Policy Summary

PayerAspirus Arise

PolicyProviders Not Participating with Medicare

Policy CodePolicy AS24P0003A1

Change TypeClarification & annual review cadence established

Effective DateJan 1, 2025

Next Review Date

Key ActionDetermine payment based on provider's Original Medicare participation status and append the AK or -GJ modifier where required.

SourceLink

POLICY UPDATE CHANGES

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.

100%Reimbursement level

115%CAH Method II max

2Products affected

AnnualReview cadence

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Required-GJ modifier required

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.

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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.

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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.

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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.

Codes, Modifiers, and Claim Edits

Codes and modifiers guidancemixed

No codes listed

Required ModifiersModifier

AK	Non Participating Physician (Critical Access Method II)
GJ	'Opt-Out' Practitioner, Emergency or Urgent Services

Claim edit types appliedmixed

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

inv-05: CAH Method II payment formula — formula summary

CAH Method II payment formula((Facility MPFS * .95) - Member Cost Share) * 1.15

ComponentsFacility-specific Medicare Professional Fee Schedule (MPFS) multiplied by non-participating reduction (0.95), less member cost-share, then multiplied by 1.15

PurposeUsed to calculate reimbursement for covered services rendered by CAH Method II practitioners who are non-participating

inv-06: CAH Method II reimbursement calculation

Reimbursement calculation expression((Facility MPFS * 0.95) - Member Cost Share) * 1.15

Applied whenMethod II practitioner does not participate with Original Medicare and AK modifier is used

Billing, Modifier and Authorization Requirements for Providers

Billing Rule

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.

Definitions and Modifier Meanings

inv-09: Participating provider — definition

DefinitionProvider who has agreed to treat Medicare patients and always accepts assignment of benefits; accepts the Medicare allowed amount as payment in full (less member out-of-pocket).

Billing implicationAccepting assignment means provider cannot balance-bill members for amounts beyond member cost-share.

Policy referenceAspirus follows Original Medicare guidance for participating providers when determining payment.

inv-10: Non-participating provider — definition

DefinitionProvider who has agreed to treat Medicare patients but does not agree to accept assignment in all cases; may accept assignment on a case-by-case basis.

Payment ruleIf they accept assignment, reimbursed at 100% of Original Medicare allowed amount (Medicare indicates minimum 95%), less member cost-share.

Policy Summary

PayerAspirus Arise

PolicyProviders Not Participating with Medicare

Policy CodePolicy AS24P0003A1

Change TypeClarification & annual review cadence established

Effective DateJan 1, 2025

Next Review Date

Key ActionDetermine payment based on provider's Original Medicare participation status and append the AK or -GJ modifier where required.

SourceLink

On This Page

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).

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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.

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Providers are required to submit claims on behalf of Aspirus Health Plan members.

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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.

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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.

Result interpretationReimbursement is the lesser of billed charge or 115% of MPFS after applying non-participating adjustment and subtracting member cost-share

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

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.

Billing implicationWhen not accepting assignment, limiting charge rules and balance-billing guidance apply per Medicare guidance.

inv-11: Opt-out provider — definition

DefinitionProvider who does not accept Medicare patients and has signed an opt-out affidavit to be excluded from Medicare programs; should not bill Medicare except in emergencies and urgent care situations.

EntitlementOpt-out providers are not entitled to payment from Aspirus Health Plan except for emergency or urgent services as allowed by Medicare.

Claim handlingClaims from opt-out providers (except emergency/urgent with -GJ) will be denied by Aspirus Health Plan.

inv-12: Modifiers (AK, GJ) — brief guidance

AK modifierDenotes Non-Participating Physician (Critical Access Method II).

GJ modifierDenotes 'Opt-Out' Practitioner for Emergency or Urgent Services. Must be appended to claim lines for such services by opt-out providers.

Modifier orderingWhen multiple modifiers are required, submit in the order listed and append additional modifiers after the listed ones as appropriate.

inv-13: Limiting Charge — definition and relevance

DefinitionLimiting Charge: The maximum dollar amount the Federal Government allows a non-participating physician to charge Medicare patients for a given service.

RelevanceDetermines maximum patient balance-billing for non-participating physicians when Medicare limiting charge applies.

Application noteFor some items (e.g., certain DME), CMS may not have limiting charges and provider charge may be used instead.

inv-14: Opt-out provider payment entitlement

EntitlementProvider who has opted out of Original Medicare is generally not entitled to payment from Aspirus Health Plan except for emergency or urgent services permitted by Medicare.

Claims handlingAspirus Health Plan will deny claims from opt-out providers except for emergency/urgent services that meet Medicare conditions.

Member protectionOpt-out status affects balance-billing and private contract rules; private contracts during opt-out can lead to denial for emergency/urgent services.

inv-15: Modifier indicating Non-Participating CAH Method II Practitioner — AK modifier

Modifier AKIndicates Non-Participating CAH Method II Practitioner; required when a Method II practitioner is non-participating.

Associated paymentWhen AK is used, providers are reimbursed at 100% of Original Medicare allowed amount (min 95%), less member cost-share; CAH Method II formula then applied.

Use caseApply on professional claims for covered services rendered by Method II practitioners who do not participate with Original Medicare.

inv-16: Modifier attesting that services by an opt-out provider were emergency or urgent — -GJ modifier

Modifier -GJAttests that services furnished by an opt-out provider were emergent or urgent; must be applied to each claim line for such services.

Denial conditionIf -GJ is not appended to claim lines from an opt-out provider for emergency/urgent services, Aspirus Health Plan will deny the claim.

Private contract caveatAspirus Health Plan will deny reimbursement for emergency/urgent services if provider and member entered a private contract during the provider's opt-out period.