CurrentHumanaPolicy CP2014105

Medicare Opt-Out

This policy governs how Humana Medicare Advantage (MA) plans handle claims and payments when a provider has formally opted out of the Medicare Program, including member reimbursement rules and conditions for emergency/urgent services. It applies to providers furnishing services to Humana MA members and to Humana MA plan processing of related claims.

Policy Summary

PayerHumana

PolicyMedicare Opt-Out

Policy CodePolicy CP2014105

Change TypeNo material change

Effective DateMar 1, 2015

Next Review Date

Key ActionFor emergency or urgent services with no private contract, submit claims and report modifier GJ (and modifier 54 with GJ when only the intraoperative portion was furnished).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 yearsopt-out period length

15 daysreimbursement window after notification

GJrequired modifier (emergency/urgent)

54modifier for intraop portion

Humana MA Coverage for Services from Opt-Out Providers

Humana MA coverage criteria for opt-out providers

Covered when ALL of the following hierarchical rules are satisfied:

ALL of the following

Opt-out providers must not seek Medicare payment during the opt-out period; emergency/urgent services without a private contract are handled as above and require modifier GJ.
See Provider billing actions

ALL of the following

Modifier GJ: indicates services were rendered by an opt-out physician/practitioner for emergency or urgent services and that no private contract exists for those services.
Modifier 54: indicates billing for the surgical (intraoperative) portion only; must be submitted with GJ for intraoperative reimbursement of global surgical emergency/urgent services.

Policy Summary

PayerHumana

PolicyMedicare Opt-Out

Policy CodePolicy CP2014105

Change TypeNo material change

Effective DateMar 1, 2015

Next Review Date

Key ActionFor emergency or urgent services with no private contract, submit claims and report modifier GJ (and modifier 54 with GJ when only the intraoperative portion was furnished).

SourceLink

On This Page

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Required Modifiers and Reimbursement Limits

Required modifiers for opt-out provider claimsModifierCovered

GJ	Modifier GJ indicates the services were rendered by an opt-out physician or practitioner for emergency or urgent services; must be reported when submitting a charge for an emergency or urgent care service and Humana MA plans deny a charge submitted by an opt-out provider without modifier GJ.
54	Modifier 54 indicates the surgeon is billing the surgical (intraoperative) portion only; when an opt-out provider renders emergency or urgent global surgical services, submit modifier 54 along with GJ and Humana MA plans reimburse only the intraoperative portion of the base maximum amount payable under the member's plan.

Reimbursement limitation — Humana MA

Humana MA reimbursement limits for opt-out provider servicesHumana MA plans may apply reimbursement limitations (for example, limiting charge amounts) when reimbursing services rendered by providers who have opted out of Medicare.

Scope of limitationsLimits apply specifically when Humana reimburses services from opt-out providers (e.g., emergency/urgent care where no private contract exists); Humana may adjust allowed amounts as appropriate.

Potential adjustment methodsExamples of limitation methods include limiting charge amounts or applying plan base maximums to determine payment.

Provider Billing and Opt-Out Obligations

Billing Rule

Billing requirements when provider has opted out of Medicare

Opt-out providers must not request Medicare payment during their opt-out period. For emergency or urgently needed services when no private contract exists, submit the claim to Medicare and report modifier GJ when billing Humana MA plans; medical records must substantiate the emergency/urgent nature. For emergency/urgent global surgical services when only the intraoperative portion was furnished, submit modifier 54 with GJ; Humana MA plans will reimburse only the intraoperative portion of the base maximum amount payable under the member's plan.

Do not request payment from Medicare during the opt-out period except as allowed for emergency/urgent services with no private contract (submit claim to Medicare on behalf of beneficiary).
When billing Humana MA for emergency/urgent services from an opt-out provider, report modifier GJ and retain medical records to substantiate emergency/urgent care.
If only the intraoperative portion of an emergency/urgent global surgical service was furnished, bill modifier 54 together with GJ; reimbursement is limited to the intraoperative portion of the plan's base maximum amount.

Key Definitions and Modifier Meanings

Base maximum amount payable under the member's plan

DefinitionThe maximum amount of reimbursement for a unit of a covered expense as determined by the member's plan (may be the maximum allowable fee, applicable Medicare fee schedule rate, or an amount from another payment model).

Plan-specific varianceActual plan reimbursement may be less than the base maximum amount because of applicable adjustments under the member's plan.

Use with opt-out provider paymentsHumana may use the base maximum amount payable under the member's plan when determining reimbursement for services rendered by opt-out providers (subject to other limits).

Modifier 54

Modifier 54 meaningIndicates the surgeon is billing for the surgical (intraoperative) portion only (surgical care only).

When to appendAppend Modifier 54 to the procedure code that describes a surgical procedure performed that has a 10- or 90-day postoperative period.

Use with opt-out surgical servicesWhen only the intraoperative portion of a global surgical service is furnished by an opt-out provider, Modifier 54 is used (often submitted along with GJ per policy rules).

Modifier GJ

Modifier GJ meaningIndicates the services were rendered by an opt-out physician or practitioner for emergency or urgent services and that no private contract exists for those services.

Implication for billingUse of Modifier GJ signals the provider opted out and that emergency/urgent services were furnished without a private contract between provider and beneficiary.

Required for Humana MA reimbursementHumana MA requires reporting of Modifier GJ when reimbursing emergency or urgent services from opt-out providers.

Member notification letter

PurposeNotice from the MA plan to the beneficiary that the physician/practitioner has opted out and must privately contract for services rendered.

Content requirementExplains private contracting and that no further payment will be made to the beneficiary for services furnished by the opt-out physician/practitioner after 15 days from the postmark of the notice.

Timing impact on reimbursementServices rendered more than 15 days after the postmark of the member notification letter are not eligible for further payment from the MA plan.