Billing members for non-covered services

We would like to provide some reminders regarding the steps a contracted provider must take prior to billing CarePartners of Connecticut members for non-covered services.    

Members may come to their provider seeking a non-covered service, or you as a provider may determine that it is appropriate to provide a service or treatment that isn’t normally covered by the member’s plan. Please note that you cannot directly bill the member for that service unless the member has been formally advised by the plan that the service will not be covered. In order to bill the member, you must first request a plan review by submitting an organization determination request to the plan. If the plan makes a non-coverage determination and the member wants to proceed with treatment, you must obtain the member’s informed written consent, which must include the specified non-covered service as well as the specific charge to the member.   

Submitting an organization determination   
Providers sometimes inform their patients that a service is non-covered and offer to provide the service in exchange for a cash payment without seeking an organization determination in advance from CarePartners of Connecticut. This is an inappropriate billing practice and is not allowed by CarePartners of Connecticut or Medicare.   

Before providing a non-covered medical service for a member and accepting payment for the service, providers are required to request an organization determination on the member’s behalf or advise the member to request such a determination. After an organization determination is requested, the provider and member will be notified of the decision. Both a denial notice from the plan, as well as valid informed written consent from the member, must be received before the provider can bill the member. You can submit an organization determination request for a medical service via fax to Precertification Operations at 857-304-6463.   

The appropriate course of action before prescribing a non-covered prescription drug is to submit a coverage determination request to the plan, which you can do by phone at 1-888-341-1507 (TTY: 711), or by filling out a Request for Medicare Prescription Drug Coverage Determination form and sending it by fax to 617-673-0956 or by mail to:   

CarePartners of Connecticut   
Attn: Pharmacy Utilization Management Department   
1 Wellness Way Canton, MA 02021-1166  

You can also submit a coverage determination request online via PromptPA at https://point32health.promptpa.com.  

If the plan denies coverage, the provider must obtain the member’s informed written consent before prescribing the drug.   

Reminder: ABNs not valid for Medicare Advantage members   
As a reminder, the process of submitting an Advance Beneficiary Notice of Non-coverage (ABN) is applicable for Original Medicare only, and is not considered a valid form of denial notice for a CarePartners of Connecticut member.   

More information  
For further details and instructions related to the correct process for billing members for non-covered services, please refer to the CarePartners of Connecticut Provider Manual.