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 CFR 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.The rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program. You can find this rule at 2 CFR  424.505 Basic Enrollment Requirements.The rules say that while a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service A/B MAC (A), (B), or (HHH) of CMS.  These claims are subject to the usual Medicare rules of payment, but only for the following services: 1.Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;2.Services of the enrollee's attending physician if the physician is not employed by or under contract to the enrollee's hospice;3.Services not related to the treatment of the terminal condition while the beneficiary has elected hospice; or4.Services furnished after the revocation or expiration of the enrollee's hospice election until the full monthly capitation payments begin again.  Monthly capitation payments will begin on the first day of the month after the beneficiary has revoked their hospice election.Medicare hospices bill the Medicare fee-for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage just as they do for beneficiaries with fee-for-service coverage.  Billing begins with a notice of election for an initial hospice benefit period, and followed by claims with types of bill 81X or 82X.  If the beneficiary later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42, should be submitted as soon as possible so that the beneficiary's medical care and payment is not disrupted. Medicare physicians may also bill the Medicare fee-for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met.  These claims should be submitted with a GV or GW modifier as applicable.  A/B MACs (HHH) process these claims in accordance with regular claims processing rules.  When these modifiers are used, A/B MAC (HHH) are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems.As specified above, by regulation, the duration of payment responsibility by fee-for-service A/B MACs (HHH) extends through the remainder of the month in which hospice is revoked by hospice beneficiaries.  MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service A/B MACs (HHH) as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.You can find this information in the Medicare Claims Processing ManualChapter 11 -Processing Hospice Claims 30.4 -Claims From Medicare Advantage Organizations.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 on page 45 of the plan's 2019 Evidence of Coverage.