50.8 – Service or Benefit Received Prior to Notice of Decision

Part C Only

If an enrollee has requested a standard pre-service reconsideration but the MA plan becomes aware that the enrollee has obtained the service before the MA plan completes its reconsideration, processing stops and the MA plan must dismiss the request. When the claim is subsequently submitted for payment, the MA plan should make its determination on whether to pay for the service. If the MA plan denies payment, it will then issue either an Integrated Denial Notice (IDN) or a system generated explanation of the enrollee’s benefit and applicable appeal rights. The denial at that stage will be an organization determination.

In such cases, if the MA plan does not become aware that the enrollee has already received the service but forwards the adverse pre-service reconsideration case to the IRE [independent review entity], the IRE will dismiss the pre-service reconsideration request when the IRE receives information indicating that the service has already been obtained.