Medicare and Other Third-party Coverage

(A) For members with Medicare and other third-party-liability coverage, see 130 CMR 450.316 through 450.318. (B) When Medicare or another third-party payer denies a claim for orthotic services, the provider is required to have a MassHealth prior authorization (PA) in place for all orthotics the MassHealth agency, or its designee identifies as subject to PA in the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool or other guidance specified by MassHealth or its designee, or as otherwise required by 130 CMR 442.000 or 130 CMR 450.303: Prior Authorization. (C) The MassHealth agency, or its designee, may request documentation of a provider’s diligent efforts to collect payment from Medicare or other liable parties, including documentation of compliance with Medicare's billing and authorization requirements. If documentation requested by the MassHealth agency, or its designee is not received within the timeframe specified, or the documentation is incomplete or does not support payment by MassHealth, the associated claims will be denied. If the MassHealth agency determines that a provider did not make diligent efforts to bill other insurances and that other liable parties should have been billed, the provider will be subject to audits. (130 CMR 442.415 Reserved)