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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 for MPFS payment purposes the determinant of payment is the locality where the physician
or supplier furnished the service. Medicare has both facility and non-facility designations for services paid
under the physician fee schedule. In accordance with Chapter 1, Section 10.1.1 (Payment Jurisdiction Among
Local Medicare Administrative Contractors (MACs) for Services Paid Under the Physician Fee Schedule and
Anesthesia Services) of this manual, the jurisdiction for processing a request for payment for services paid
under the MPFS is governed by the payment locality where the physician or supplier furnished the service and
will be based on the ZIP code. CMS requires that the address and ZIP code of the physician's practice location
be placed on the claim form in order to determine the appropriate locality -- item 32 on the paper claim Form
CMS 1500 or in the corresponding loop on its electronic equivalent. For specific POS instructions and
determination of the applicable payment locality for the PC (professional interpretation) and the TC of
diagnostic tests see chapter 13, section 150 of this manual. For general policy on POS code assignment, see
chapter 12, section 20.4.2 of this manual regarding the site of service payment differential under MPFS. If the
physician bills for lab services performed in his/her office, the POS code for "Office" is shown. If the physician
bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for "Other" is
shown. If the physician bills for a lab service furnished by an independent lab, the code for "Independent
Laboratory" is used. Items 21 and 22 on the Form CMS-1500 must be completed for all laboratory work
performed outside a physician's office. If an independent lab bills, the place where the sample was taken is
shown. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an
independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the
code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient
hospital (POS code 22), respectively. You can find this information in Medicare's Claims Processing Manual;
Chapter 26 - Completing and Processing; 10.6 - A/B Medicare Administrative Contractor (MAC) (B)
Instructions for Place of Service (POS) Codes (Rev. 3490, Issued: 04-01-16, Effective: 04-25-16,
Implementation: 04-25-16).
Medicare Guidance says unless otherwise specified, the MAC, RAC and ZPIC/UPIC shall request information
from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit
the requested documentation. However, because the provider selected for review is the one whose payment is
at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the
documentation requested by the MAC, CERT, RAC and ZPIC/UPIC. &#769;You can find this guidance in the
Medicare Program Integrity Manual, Chapter 3 -Verifying Potential Errors and Taking Corrective Actions,
Section 3.2.3.3 - Third-party Additional Documentation Request.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.