Medicare Advantage Plan - JE Part B

Common Reasons for Message

• Patient enrolled in a Medicare Advantage (MA) plan on date of service
  • Certain MA plans take place of Original Fee-For-Service Medicare
• Patient's Common Working File (CWF) file has not been updated to show disenrollment from MA plan
• Patient is enrolled in an MA plan and also elected hospice
  • Original Medicare covers attending physician services and all care unrelated to terminal illness
  • Appropriate modifier(s) is missing from claim
• Patient enrolled in MA plan and also in a clinical trial
  • Original Medicare covers routine costs of services for qualifying clinical trials

Next Step

• Verify patient's eligibility via Interactive Voice Response (IVR) or the Noridian Medicare Portal
  • If MA plan valid, bill services to appropriate insurer
  • If MA plan has been updated and is no longer valid for date of service, submit new claim
• Refile claim with appropriate modifiers
  • Modifier GV - Attending physician is not employed or paid under agreement by the patient's Hospice provider
  • Modifier GW - Condition not related to the patient's terminal condition
  • Modifier Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study
  • Modifier Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study
• Submit a Reopening request,
  • Add appropriate modifier(s), if time limit for filing claim has expired
  • If MA plan was not valid, request reprocessing of claim

Claim Submission Tips

• Prior to rendering services, obtain patient's health insurance card