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Question about Capitation Agreement/Managed Care Plan

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TMCGEATH:
When I billed Medicare for a psychotherapy session, I got this message back instead of a payment - "Charges are covered under a capitation agreement/managed care plan". This is a new one for me - any help would be appreciated!

PMRNC:
Sounds like they have a Medicare Advantage Plan.  Was a benefits verification done? Info should be on the patient ID card.

Michele:
Many times the patient's don't even realize they have signed up for something separate.  They just think they have Medicare.  Definitely a Medicare Advantage Plan.  If you have online lookup capabilities they usually list the Advantage Plan.  The automated system will also usually tell you as well.  The patient will have an insurance card in addition to their Medicare card.  These Advantage Plans have separate ID numbers and don't use the Medicare ID# (ss# followed by a letter). 

TMCGEATH:
I think that is exactly what happened - the client only gave my provider her Medicare card, and I'll be honest, I didn't go onto my local Medicare Administrators Website to look at anything because all his Medicare up to now have been "straight Medicare" - lesson learned!

Okay, at this point, what do I do? The ERA didn't make it sound like it was being forwarded anywhere. Was I supposed to bill Optimum HealthCare instead of Medicare for this patient? I helped this same provider with insurance paneling and we did not get contracted with Optimum so what does that mean?

AAAAHHHH! LOL! Help!

PMRNC:

--- Quote ---Okay, at this point, what do I do? The ERA didn't make it sound like it was being forwarded anywhere. Was I supposed to bill Optimum HealthCare instead of Medicare for this patient? I helped this same provider with insurance paneling and we did not get contracted with Optimum so what does that mean?
--- End quote ---

You will want to make a call and verify benefits and claims address.. If the patient didn't give you the correct card the first time around, they should be responsible for their portion if you are not in network. At this point you want to look at the ID card and call. If it's not the correct card you will need to get the correct information from the patient. If you can't, send them a bill for the whole balance, that usually gets them moving.

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