PHP, HMO, Triwest

PHP, HMO, Triwest, and other comprehensive health plans (for example, Kaiser, Secure Horizons) must be billed prior to billing MC. MC will reject bills for services provided to beneficiaries with OHC codes “F”,”K”, “C”, or “P” with the exception of the following:

The service is not a covered benefit under the designated plan (e.g., eye glasses, dental, prescriptions)
The service is determined to be a medical emergency and occurs outside of the plan's geographic service area (i.e., individuals with Kaiser must use their Kaiser coverage when within a 30-mile radius of any Kaiser facility).

Note: For either of these situations, the provider must attach the OHC denial letter to the claim when submitting a bill for MC payment.

PHP, HMO, Triwest

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