CMS Pub. 100-16, ch. mc86c17f, § 10.10

(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)

If a Cost plan enrollee receives services:

• Under the direction or authorization of a plan physician;

• Correctly identifies himself or herself as a member of that plan to the contracted

provider before receiving the items or services; and

• (The enrollee) has not been informed that he or she is liable for the costs of such

services,

then the plan must cover such services. This means that the plan does not have the

right, after a service is received, to retroac tively overturn a plan physician's decision

that an item or service is medically reasonable and nece ssary. For example, a plan

cannot retroactively deny a contracted physi cian's referral of a member for specialty

care even when there are plan preauthorization requirements. In such a case the

plan cannot penalize the member if a contra cting provider fails to follow plan

preauthorization rules.

An enrollee is considered informed that he or she is liable for the costs of a service if:

• The enrollee should be expected to know the service is not covered by Medicare

or under the plan, e.g., acupuncture; or

• The contracting provider explicitly advises the enrollee prior to the service or

referral that the service is not or will not be covered.

Although a plan may require the Medicare enrollee to receive prior authorization from a

primary care physician or a gatekeeper before specialty care is received, if a plan

physician provides or directs a beneficiary to receive a covered Medicare service without

following the plan’s internal procedures, then the plan must pay for the service. A

beneficiary who has already received a service may not be penalized if the authorizing

physician's referral was improper or the specialist delivered the service without the

necessary authorization.

The enrollee should never pay more than the plan required cost sharing - coinsurance,

deductibles and copays.