By Becky Amann, Compliance Manager
Medicare – Exclusions From Coverage
National Government Services (NGS) recently published an article regarding: Charges Imposed by Immediate Relatives of the Patient or Members of Household. NGS has recently identified claims submitted by providers who furnished services to their immediate relatives or to members of their household. Medicare does not pay for these services, since they are ordinarily furnished gratuitously because of the relationship between the Medicare beneficiary and the provider. Immediate relatives are defined as:
- Husband or wife
- Natural or adoptive parent, child and sibling
- Stepparent, stepchild, stepbrother or stepsister
- Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law or sister-in-law
- Grandparent or grandchild
A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or death of one of the parties.
Members of Household are defined as:
Persons sharing a common abode with the patient as part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.
This Medicare exclusion applies whether the provider is a sole proprietor who has a relationship (as identified above) to the patient, or a partnership in which one of the partners is related to the patient.
Please refer to the Medicare Benefit Policy Manual, Chapter 16, Section 130 for further information regarding these exclusions from coverage. The Medicare manuals are located on CMS’s website under their Guidance section at:
*** Please note: These exclusions also pertain to Medicare Advantage Plans ***
Univera – Risk Adjustment Review of Medical Records
Univera has contracted with Verisk Health to retrieve medical record documentation from providers. The record retrieval is a necessary part of their Risk Adjustment Program that is designed to capture the medical complexity of their Medicare Advantage members. CMS requires Medicare Advantage plans to confirm that the diagnosis codes submitted via claims are supported in the medical records. The record review also ensures the documentation properly reflects the clinical conditions of the patient.
Verisk Health will begin contacting selected providers in July to schedule the retrieval of medical records reflecting services rendered from January 1, 2014 to present.
For Compliance questions, please contact Becky Amann at 716-348-3902 or firstname.lastname@example.org<