Medicare Advantage (MA) plans must cover all services that Original Medicare covers, but they can add prior authorization requirements and use different networks. Coverage details vary by plan and carrier. Use Medicare.gov Plan Finder and the carrier's provider portal to verify specific plan benefits.
Before service: Verify MA plan benefits on carrier portal. Check PA requirements. Day of service: confirm active enrollment. After service: submit claim to the MA plan, not to Original Medicare. If denied: appeal within 60 days for organization determination.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-50 | Non-covered service | Service not in MA plan benefits | Verify plan-specific coverage |
| CO-197 | Precertification absent | PA required by MA plan | Check plan's PA list |
| CO-11 | Medical necessity | Plan clinical criteria not met | Include documentation meeting CMS/plan criteria |
MA plan denials follow CMS rules. Request a reconsideration within 60 days of the initial organization determination. If denied: appeal to Independent Review Entity (IRE). Then: ALJ hearing if amount exceeds $190 (2026 threshold). CMS response timelines: 7 days standard, 72 hours expedited.
Check the plan's Evidence of Coverage (EOC) on the carrier's website, or use Medicare.gov Plan Finder. Enter the member's zip code and plan name to see covered services, copays, and PA requirements.
All MA plans must cover everything Original Medicare covers. Differences are in supplemental benefits (dental, vision, fitness), prior auth requirements, network restrictions, and cost-sharing amounts.
Submit claims directly to the MA plan, not to Original Medicare. The MA plan's payer ID is on the member's insurance card. Use the carrier's EDI payer ID for electronic submission.
Altair verifies Medicare Advantage plan-specific coverage and PA requirements before every claim.