Appeal type: unknown
Decision: unknown

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 for dates of service on or after September 19, 2000, and until notified otherwise by CMS, 
Medicare contractors will pay for covered clinical trial services furnished to beneficiaries enrolled in managed 
care plans.  Providers who furnish covered clinical trial services to managed care beneficiaries must be enrolled 
with Medicare in order to bill on a fee-for-service basis.  Providers that wish to bill fee for service but have not 
enrolled with Medicare must contact their local carrier, intermediary, regional home health intermediary or 
National Supplier Clearinghouse, as appropriate, to obtain an enrollment application. Determine payment for 
covered clinical trial services furnished to beneficiaries enrolled in managed care plans in accordance with 
applicable fee for service rules, except that beneficiaries are not responsible for the Part A or Part B deductibles 
(i.e., assume the Part A or Part B deductible has been met).  Managed care enrollees are liable for the 
coinsurance amounts applicable to services paid under Medicare fee for service rules. The clinical trial coding 
requirements for managed care enrollee claims are the same as those for regular Medicare fee for service 
claims.  However, for beneficiaries enrolled in a managed care plan, institutional providers must not bill 
outpatient clinical trial services and non-clinical trial services on the same claim.  If covered outpatient services 
unrelated to the clinical trial are rendered during the same day/stay, the provider must split-bill so that ONLY 
the clinical trial services are contained on a single claim and billed as fee-for-service (this allows the Medicare 
claims processing system to not apply deductible when the patient is found to be in a managed care plan).  Any 
outpatient services unrelated to the clinical trial should be billed to the managed care plan. You can find this 
information in the Medicare Claims Processing Manual, Chapter 32, Section 69.9. 
 
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. The health 
plan contract states, "Original Medicare pays most of the cost of the covered services you receive as part of the 
study. After Medicare has paid its share of the cost for these services, our plan will also pay for part of the 
costs. We will pay the difference between the cost-sharing in Original Medicare and your cost-sharing as a 
member of our plan. This means you will pay the same amount for the services you receive as part of the study 
as you would if you received these services from our plan. In order for us to pay for our share of the costs, you 
will need to submit a request for payment. With your request, you will need to send us a copy of your Medicare 
Summary Notices or other documentation that shows what services you received as part of the study and how 
much you owe. Please see Chapter 7 for more information about submitting requests for payment." You can 
find this information in Chapter 3 on page 52 of the plan's 2020 Evidence of Coverage.