CMS Pub. 100-16, ch. mc86c16a, § 100

42 CFR 422.216(e)

If a member of a full, partial, or non-network PFFS plan sees a deemed provider who

agrees to accept the plan’s terms and conditions of payment, then the member and the

provider have the right to request a written advance organization determination (also

known as an advance coverage determination) from the plan before the member receives

a service from the deemed provider. This allows the member and the provider to confirm

that the service is medically necessary and a covered service, and therefore, will be paid

for by the plan. The PFFS plan must make advance organization determinations in

accordance with Subpart M of Part 422 and Chapter 13 of this manual.

In the absence of an advance organization determination, a PFFS plan can retroactively

deny payment for a service furnished to a member only if the plan determines that the

service was not covered by the plan or was not medically necessary. However, members

and providers have the right to dispute the plan’s decision by exercising member appeals

rights. Refer to Chapter 13 of this manual for more information.

PFFS plans should take an active role to educate their members and providers about their

right to request a written advance organization determination from the plan before a

member receives a service in order to confirm that the service is medically necessary and

will be covered by the plan. PFFS plans should clearly explain the process for requesting

an initial organization determination in member materials and respond to requests from

members and providers on a timely basis as described in subpart M section 422.568 and

422.572. PFFS plans should also encourage members and providers to request advance

organization determinations prior to receiving costly services.