Last Modified: 10/13/2011 Location: FL, PR, USVI Business: Part B
Charges are covered under a capitation agreement/managed care plan.
(THIS CLAIM MUST BE SUBMITTED TO THE PATIENT'S HMO)
Resources/tips for avoiding this unprocessable claim
This return usually means a beneficiary has a Medicare Advantage (MA) plan or payment for services is covered under a capitation agreement.
• MA enrollment information can be obtained through the Part B IVR (at 1-877-847-4992).
• Claims must be submitted to the MA plan before Medicare.
• Prior to seeing a patient for end-stage renal disease (ESRD) related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.
Tips to correct the unprocessable claim
• Medicare Advantage (MA) -- If the beneficiary is enrolled in an MA plan, this return is appropriate. Submit the claim to the MA plan.
• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service options Inc. (FCSO).
• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.
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Source: FCSO Education Action Team