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Medicare Denial Requirements for Dual Eligibles
February 2, 2007

Interpretation of third party liability requirements has prompted some HealthChoices behavioral health managed care organizations to require providers to obtain a Medicare denial for services for individuals dually eligible for Medicare and Medical Assistance (MA) when the provider is not Medicare certified. This has occurred frequently in partial hospitalization services where there are very few Medicare-certified providers in Pennsylvania. When the provider is not Medicare certified and does not have a Medicare provider identification number, there is no formal process for requesting a denial for services. Non-certified providers should draft a letter requesting a denial and send it to:

Highmark Medicare Services
Attn: Customer Contact Center
PO Box 890385
Camp Hill, PA 17089-0385

Providers may wait up to 45 days for a response to a request.

If the provider has a Medicare provider number and is able to submit claims, then the provider should enter condition code 21 in the claim form to indicate that the furnished service is excluded, but a denial notice is needed from Medicare in order to bill other insurers.

The Office of Mental Health and Substance Abuse Services has convened a work group on third party liability issues and is examining the issue of denials for Medicare services. The work group is in contact with representatives of the Centers for Medicare and Medicaid Services to determine whether any alternatives to receipt of a denial for a non-Medicare certified provider are possible.

Please contact Betty Simmonds at PCPA with questions or to discuss problematic situations.

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