Common use of Payments for Services to Medicare-Eligible Individuals with Other Medicare Coverage Clause in Contracts

Payments for Services to Medicare-Eligible Individuals with Other Medicare Coverage. 3.6.1 If a Medicare-eligible individual is ineligible as a MA Member on the date of service, MA Plan will not be liable for payments. Dentist may seek payment from the Medicare-eligible individual’s primary payor. 3.6.2 If MA Plan erroneously identifies a Medicare-eligible individual as a MA Member, MA Plan will be liable for payments if Dentist cannot seek payment from the Medicare-eligible individual’s primary payor. 3.6.3 MA Plan will be liable to Dentist for Covered Services rendered to a Member who erroneously represented to the Dentist that the MA Member had coverage under another private dental and/or health plan’s Medicare program (“Other Medicare Coverage”), so long as the circumstances satisfy the following conditions: (a) Dentist can document that the MA Member was previously covered under Other Medicare Coverage; (b) Dentist provided Covered Services on the good faith belief that the MA Member was covered under such Other Medicare Coverage as of the date of service; (c) relying on conditions (a) and (b), Dentist was unaware of the application of MA Plan’s Preauthorization requirements; (d) Dentist’s services satisfy MA Plan’s Medical Necessity and Appropriateness criteria; and (e) under the circumstances, MA Plan would have otherwise approved a Preauthorization request for the services provided to the MA Member.