CurrentHumanaPolicy CP2014105

Medicare Opt-Out

This policy governs Humana Medicare Advantage (MA) plan payment treatment when a provider has formally opted out of the Medicare Program and the related private contracting and reimbursement rules that apply to Humana MA members and providers.

Policy Summary

PayerHumana

PolicyMedicare Opt-Out

Policy CodePolicy CP2014105

Change TypeNo material change

Effective DateMar 1, 2015

Next Review Date

Key ActionWhen submitting emergency or urgent charges to Humana MA from an opt-out provider without a private contract, report modifier GJ and include modifier 54 for intraoperative global surgical billing as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 yearsopt-out period length

15 daysmember reimbursement window

GJ, 54required modifiers

No reimbursementreimbursement for private contract

Coverage Criteria

inv-01: COVERAGE CRITERIA

Humana MA payment rules when a provider has opted out of Medicare:

Humana MA plans do not reimburse charges for services rendered pursuant to a valid private contract between an opt-out provider and an MA member.

Humana may recoup any claim payment made for a service furnished by an opt-out provider if it is determined a private contract was in effect at the time of service.

Humana MA plans deny a charge submitted by an opt-out provider for services that are not emergency or urgent care.

Humana MA plans may reimburse charges for emergency or urgent services rendered and submitted by an opt-out provider only if no private contract exists between the provider and the MA member, and medical records substantiate the emergency/urgent nature of the service.

Policy Summary

PayerHumana

PolicyMedicare Opt-Out

Policy CodePolicy CP2014105

Change TypeNo material change

Effective DateMar 1, 2015

Next Review Date

SourceLink

On This Page

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Coding and Reimbursement Rules

Required modifiers for opt-out provider claimsModifierCovered

GJ	Indicates services rendered by an opt-out physician/practitioner for emergency or urgent services when no private contract exists.
54	Indicates surgeon is billing the intraoperative surgical care only (used with global surgical services).

Reimbursement limitation — Humana MA plans may limit charge amounts and reimburse only amounts appropriate under member's plan

PolicyHumana MA plans may limit allowed charge amounts and reimburse only amounts appropriate under the member's plan when reimbursing services rendered by an opt-out provider.

ExampleWhen modifier 54 is billed for the intraoperative portion of a global surgical service, Humana reimburses only the intraoperative portion of the base maximum amount payable under the member's plan.

ScopeLimitations apply when Humana determines it is appropriate to limit charge amounts for services by an opt-out provider (e.g., emergency/urgent services with required modifiers).

EffectActual plan reimbursement may be less than the base maximum amount because of applicable adjustments under the member's plan.

Provider Billing & Submission Actions

Billing Rule

Opt-out Provider Billing & Submission Requirements

Providers who have opted out of the Medicare Program must not request payment from the Medicare Program for services furnished during their opt-out period. The provider and the Humana Medicare Advantage (MA) member must have a private contract for services that Medicare would otherwise cover; under such a contract the beneficiary agrees to pay the provider directly and Medicare payment rules and charge limitations do not apply. Exception: for emergency or urgently needed services when no private contract exists, an opt-out provider may request payment from Medicare and must submit the claim to Medicare on behalf of the beneficiary. Humana MA plans will reimburse an opted-out provider only for emergency or urgent care services when no private contract exists and when the claim is submitted with the required modifier (see items). Medical records must substantiate that the service was emergency or urgently needed.

When submitting a charge for an emergency or urgent care service, an opt-out provider must report modifier GJ.
Humana MA plans deny charges submitted by an opt-out provider that do not include modifier GJ.
When an opt-out provider furnishes emergency or urgent global surgical services and only the intraoperative portion was provided, submit modifier 54 in addition to modifier GJ; Humana MA plans will reimburse only the intraoperative portion of the base maximum amount payable under the member's plan.

Definitions

Base maximum amount payable under the member's plan — definition

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

ApplicationUsed as the reference amount when Humana calculates payment for services rendered by opt-out providers; actual reimbursement may be less due to plan adjustments.

VariabilityDepending on the plan, the base maximum amount can vary by payment model and may not represent the final paid amount.

Modifier 54 — indicates the surgeon is billing the surgical care only (intraoperative)

Modifier 54 meaningIndicates the surgeon is billing the surgical care only (intraoperative) for procedures with a 10- or 90-day postoperative period.

Use with opt-out emergency/urgent global surgeryWhen an opt-out provider renders emergency or urgent global surgical services, submit modifier 54 to indicate only the intraoperative portion was furnished along with modifier GJ.

Billing practiceAppend modifier 54 to the procedure code that describes the surgical procedure to identify intraoperative-only billing.

Modifier GJ — indicates services rendered by an opt-out physician/practitioner for emergency or urgent services

Modifier GJ meaningIndicates the services were rendered by an opt-out physician or practitioner for emergency or urgent services when the provider has not signed a private contract with the beneficiary.

RequirementAn opt-out provider must report modifier GJ when submitting a charge for an emergency or urgent care service; charges without GJ are denied.

Supporting documentationMedical records must be available to substantiate that the service was truly emergency or urgent when GJ is reported.

Member notification letter — definition and 15-day member response window

DefinitionWritten notice from the MA plan informing the beneficiary that the provider has opted out of Medicare and must privately contract for services.

Member action windowMembers may submit reimbursement requests for services rendered 15 or fewer days after the postmark of the member notification letter; Humana does not reimburse services rendered more than 15 days after the postmark.

First-claim reimbursementIf Humana reimburses any charge received on a member-submitted claim, Humana will send the member a notification letter.