Question:

Does a benefit category denial cause the financial liability protection provisions of Limitation On Liability (§1879) to be enacted?

Answer:

According to the Medicare Benefit Policy Manual, “A benefit category denial (i.e., a denial based on the fact that there is no benefit category under which the drug may be covered) does not trigger the financial liability protection provisions of Limitation On Liability (under §1879 of the Act). Therefore, physicians or providers may charge the beneficiary for an excluded drug.”

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