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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the Current
Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the
Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for
Medicare Services, Chapter I(A).
The rules say that the transportation component represents the transportation of the equipment to the patient.
Establish local RVUs for the transportation R codes based on Medicare Administrative Contractor (MAC)
knowledge of the nature of the service furnished. The MACs shall allow only a single transportation payment
for each trip the portable x-ray supplier makes to a particular location. When more than one patient is x-rayed
at the same location, e.g., a nursing home, prorate the single fee schedule transportation payment among all
patients (Medicare Parts A and B, and non-Medicare) receiving the portable x-ray services during that trip,
regardless of their insurance status. For example, for portable x-ray services furnished at a Skilled Nursing
Facility (SNF), the transportation fee should be allocated among all patients receiving portable x-ray services at
the same location in a single trip irrespective of whether the patient is in a Part A stay, a Part B patient, or not a
Medicare beneficiary at all. If the patient is in a Part A SNF stay, the transportation and set up costs are subject
to consolidated billing and not separately billable to Medicare Part B. For a privately insured patient, it would
be the responsibility of that patient's insurer. For a Medicare Part B patient, payment would be made under Part
B for the share of the transportation fee attributable to that patient. You can find this rule in the Medicare
Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures 90.3 -
Transportation Component (HCPCS Codes R0070 - R0076) (Rev. 3387, Issued: 10-30-15, Effective: 01-01-16,
Implementation: 01-01-16).
The rules say that when a SNF resident receives a portable x-ray service during the course of a Medicarecovered
stay in the SNF, only the service's professional component (representing the physician's interpretation
of the test results) is a separately billable physician service under Part B (see 20.1 of this chapter and 20.1.1
of Chapter 6). By contrast, the technical component representing the procedure itself, including any associated
transportation and setup costs, would be subject to consolidated billing (the SNF "bundling" requirement for
services furnished to the SNF's Part A residents), and must be included on the SNF's Part A bill for the
resident's covered stay (Bill Type 21x) rather than being billed separately under Part B (see 20.2.1of this
chapter). You can find this rule in the Medicare Claims Processing Manual Chapter 13 - Radiology Services
and Other Diagnostic Procedures 90.3 - Transportation Component (HCPCS Codes R0070 - R0076) (Rev.
3387, Issued: 10-30-15, Effective: 01-01-16, Implementation: 01-01-16).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.