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Attention new Arkansas Blue Medicare members
If you have enrolled in an Arkansas Blue Medicare plan and have not yet received your member ID card, welcome kit or first invoice, please know that your coverage will still start January 1, 2021. If you selected to pay your premium via check, you will receive an invoice. Once you receive your invoice, you can pay your bill by check. Please call customer services at 800-220-5779 if you have any questions.
BlueMedicare Private Fee-for-Service (PFFS) plan offered by Arkansas Blue Medicare. Arkansas Blue Medicare and/or Health Advantage allows members to use any provider, such as a physician, health professional, hospital, or other Medicare provider in the United States that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B (also known as "Original Medicare") or eligible to be paid by Arkansas Blue Medicare and/or Health Advantage for benefits that are not covered under Original Medicare.
The law provides that if you have an opportunity to review these terms and conditions of payment and you treat a Arkansas Blue Medicare and/or Health Advantage member, you will be "deemed" to have a contract with Arkansas Blue Medicare and/or Health Advantage. Section 2 explains how the deeming process works. The rest of this document contains the contract that the law allows Arkansas Blue Medicare and/or Health Advantage to deem to hold between you, the provider, and Arkansas Blue Medicare and/or Health Advantage. Any provider in the United States that meets the deeming criteria in Section 2 is deemed to have a contract with Arkansas Blue Medicare and/or Health Advantage for the services furnished to the member when the deeming conditions are met. No prior authorization, prior notification or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to a member. However, a member or provider may request an advance organization determination before a service is provided in order to confirm that the service is medically necessary and will be covered by the plan. Section 7 describes how a provider can request an advance organization determination from the plan.
Arkansas Blue Medicare and/or Health Advantage has signed contracts with some providers. These providers are our network providers. Our members can still receive services from non-network providers who do not have a signed contract with us, as long as the provider meets the deeming criteria described in Section 2. These deemed contracting providers are subject to all of the terms and conditions of payment described in this document.
To access the list of providers who participate with Arkansas Blue Medicare and/or Health Advantage go to: https://secure.arkansasbluecross.com/provider_directory/ then select the Guest search option. In the list under "Search All Medicare Advantage Medical Networks" to search for network providers. The amount of cost sharing a member pays a provider who is not one of our network providers may be more than the cost sharing the member pays a network provider. We indicate the services for which the cost sharing amount differs between network providers and non-network providers in the Arkansas Blue Medicare and/or Health Advantage Member Evidence of Coverage (EOC).
A provider is deemed by law to have a contract with Arkansas Blue Medicare and/or Health Advantage when all of the following three criteria are met:
The provider is aware, in advance of furnishing health care services, that the patient is a member of Arkansas Blue Medicare and/or Health Advantage. All Arkansas Blue Medicare and/or Health Advantage members receive a member ID card that includes the Arkansas Blue Cross and Blue Shield logo that clearly identifies them as Arkansas Blue Medicare (HMO/PPO/PFFS) and/or Health Advantage Medicare Advantage HMO members. The provider may validate eligibility by calling Customer Service at 1-800-287-4188. In addition, providers may check AHIN to verify member eligibility.
The provider either has a copy of, or has reasonable access to, the Medicare Advantage terms and conditions of payment (this document). The terms and conditions are available on our website at: www.arkbluecross.com.
The terms and conditions may also be obtained by calling Customer Service 1-800-287-4188.
The provider furnishes covered services to a Arkansas Blue Medicare and/or Health Advantage member.
If all of these conditions are met, the provider is deemed to have agreed to the Medicare Advantage terms and conditions of payment for that member specific to that visit. For example: If a Arkansas Blue Medicare and/or Health Advantage member shows you an enrollment card identifying him/her as a member of Arkansas Blue Medicare and/or Health Advantage and you provide services to that member, you will be considered a deemed provider. Therefore, it is your responsibility to obtain and review the terms and conditions of payment prior to providing services, except in the case of emergency services (see below).
Note: You, the provider, can decide whether or not to accept the Medicare Advantage terms and conditions of payment each time you see a Arkansas Blue Medicare and/or Health Advantage member. A decision to treat one plan member does not obligate you to treat other Medicare Advantage members, nor does it obligate you to accept the same member for treatment at a subsequent visit.
If you DO NOT wish to accept the Medicare Advantage terms and conditions of payment, then you should not furnish services to a Arkansas Blue Medicare and/or Health Advantage member, except for emergency services. If you nonetheless do furnish non-emergency services, you will be subject to these terms and conditions whether you wish to agree to them or not. Providers furnishing emergency services will be treated as non-contract providers and paid at the payment amounts they would have received under Original Medicare.
In order to be paid by Arkansas Blue Medicare and/or Health Advantage for services provided to one of our members, you must:
Arkansas Blue Medicare and/or Health Advantage reimburses deemed providers at the amount they would have received under Original Medicare for Medicare-covered services, minus any member required cost sharing, for all medically necessary services covered by Medicare.
Arkansas Blue Medicare and/or Health Advantage will pay Physician Quality Reporting Initiative (PQRI) bonus and e-prescribing incentive payment amounts to deemed physicians who would have received them in connection with treating Medicare beneficiaries who are not enrolled in Medicare Advantage plan.
Arkansas Blue Medicare and/or Health Advantage will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then Arkansas Blue Medicare and/or Health Advantage will pay interest on the claim according to Medicare guidelines. Section 5 has more information on prompt payment rules. Payment to providers for which Medicare does not have a publicly published rate will be based on the estimated Medicare amount. View the Payment Methodology [pdf] for more detailed information.
Services covered under Arkansas Blue Medicare and/or Health Advantage that are not covered under Original Medicare are reimbursed using the Arkansas Blue Medicare and/or Health Advantage fee schedule. Please call us at 877-233-7022 or 800-676-BLUE (800-676-2583) to receive information on our fee schedule.
Deemed providers furnishing such services must accept the fee schedule amount, minus applicable member cost sharing, as payment in full.
Payment of cost sharing amounts is the responsibility of the member. Providers should collect the applicable cost sharing from the member at the time of the service when possible. You can only collect from the member the appropriate Medicare Advantage co-payments or coinsurance amounts described in these terms and conditions. After collecting cost sharing from the member, the provider should bill Arkansas Blue Medicare and/or Health Advantage for covered services. Section 5 provides instructions on how to submit claims to us. Please note, however, that Arkansas Blue Medicare and/or Health Advantage may not hold members accountable for any cost-sharing (deductibles, copayments, coinsurance) for Medicare-covered preventive services that are subject to zero cost sharing.
If a member is a dual-eligible Medicare beneficiary (that is, the member is enrolled in the Medicare Advantage plan and a State Medicaid program), then the provider cannot collect any cost sharing for Medicare Part A and Part B services from the member at the time of service when the State is responsible for paying such amounts (nominal copayments authorized under the Medicaid State plan may be collected). Instead, the provider may only accept the Arkansas Blue Medicare and/or Health Advantage plan payment (plus any Medicaid copayment amounts) as payment in full or bill the appropriate State source.
For your quick reference, the pdfs below list some of the important services covered under Arkansas Blue Medicare and/or Health Advantage and the associated member cost sharing amounts.
To view a complete list of covered services and member cost sharing amounts under Arkansas Blue Medicare and/or Health Advantage go to: http://www.arkansasbluecross.com/LookingForInsurance/MedicarePlans/default.aspx?zip=undefined. You may call us at 877-233-7022 or 800-676-BLUE (800-676-2583) to obtain more information about covered benefits, plan payment rates, and member cost sharing amounts under Medicare Advantage. Be sure to have the member's ID number including the 3 character alpha prefix (on the ID card) when you call.
BlueMedicare PFFS follows Medicare coverage decisions for Medicare-covered services. Services not covered by Medicare are not covered by BlueMedicare PFFS, unless specified by the plan. Information on obtaining an advance coverage determination can be found in Section 7. BlueMedicare PFFS does not require members or providers to obtain prior authorization, prior notification or referrals from the plan as a condition of coverage. There are no prior authorization and prior notification rules for BlueMedicare PFFS members.
Note: Medicare supplemental policies, commonly referred to as Medigap plans, cannot cover cost sharing amounts for Medicare Advantage plans, including BlueMedicare PFFS plans. All cost sharing is the member's responsibility.
There are two different PFFS balance billing scenarios:
A provider may collect only applicable plan cost sharing amounts from BlueMedicare PFFSmembers and may not otherwise charge or bill members. Balance billing is prohibited by providers who furnish plan-covered services to BlueMedicare PFFS members.
In no event, including, but not limited to non-payment by Medicare Advantage, insolvency of Medicare Advantage, and/or breach of these terms and conditions, shall a deemed provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons acting on their behalf for plan-covered services provided under these terms and conditions. This provision shall not prohibit the collection of any applicable coinsurance, copayments or deductibles billed in accordance with the terms of the member's benefit plan.
If any payment amount is mistakenly or erroneously collected from a member, you must make a refund of that amount to the member.
Coordination of Benefits: All Medicare secondary payer rules apply. These rules can be found in the Medicare Secondary Payer Manual located at: http://www.cms.gov/Manuals/IOM/list.asp
Providers should identify primary coverage and provide information to Arkansas Blue Medicare and/or Health Advantage at the time of billing.
Deemed providers shall maintain timely and accurate medical, financial and administrative records related to services they render to Arkansas Blue Medicare and/or Health Advantage members. Unless a longer time period is required by applicable statutes or regulations, the provider shall maintain such records for at least 10 years from the date of service.
Deemed providers must provide Arkansas Blue Medicare and/or Health Advantage, the Department of Health and Human Services, the Comptroller General, or their designees access to any books, contracts, medical records, patient care documentation, and other records maintained by the provider pertaining to services rendered to Medicare beneficiaries enrolled in a Medicare Advantage plan, consistent with federal and state privacy laws. Such records will primarily be used for Centers for Medicare & Medicaid Services (CMS) audits of risk adjustment data upon which CMS capitation payments to Arkansas Blue Medicare and/or Health Advantage are based. Providers are required to furnish member medical records without charge when the medical records are required for government use.
Arkansas Blue Medicare and/or Health Advantage also may request records for activities in the following situations: Arkansas Blue Medicare and/or Health Advantage audits of risk adjustment data, determinations of whether services are covered under the plan, are reasonable and medically necessary, and whether the plan was billed correctly for the service; to investigate fraud and abuse; in order to make advance coverage determinations; and to document compliance with regulatory reporting requirements for quality measures. Arkansas Blue Medicare and/or Health Advantage will not use these records for any purpose other than the intended use. Providers are required to furnish these member medical records without charge.
Arkansas Blue Medicare and/or Health Advantage will not use medical record reviews to create artificial barriers that would delay payments to providers. Both mandatory and voluntary provision of medical records must be consistent with HIPAA privacy law requirements.
Providers may choose to obtain a written advance coverage determination (known as an organization determination) from Arkansas Blue Medicare and/or Health Advantage before furnishing a service in order to confirm whether the service is medically necessary and will be covered by Arkansas Blue Medicare and/or Health Advantage. To obtain an advance organization determination, call us at 877-233-7022. Arkansas Blue Medicare and/or Health Advantage will make a decision and notify you and the member within 14 days of receiving the request, with a possible 14-day extension either due to the member's request or a Arkansas Blue Medicare and/or Health Advantage justification that the delay is in the member's best interest. In cases where you believe that waiting for a decision under this time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy, you can request an expedited determination. To obtain an expedited determination, call us at 800-285-6687. We will notify you of our decision as expeditiously as the enrollee's health condition requires, but no later than 72 hours after receiving the request, unless we invoke a (up to) 14-day extension either due to the member's request orArkansas Blue Medicare and/or Health Advantage's justification (for example, the receipt of additional medical evidence may change Arkansas Blue Medicare and/or Health Advantage's decision to deny) that the delay is in the member's best interest.
In the absence of an advance organization determination, Arkansas Blue Medicare and/or Health Advantage can retroactively deny payment for a service furnished to a member if we determine that the service was not covered by our plan or was not medically necessary. However, providers have the right to dispute our decision by exercising member appeals rights (see the Federal regulations at 42 CFR Part 422, subpart M, or Chapter 13 of the Medicare Managed Care Manual).
If you believe that the payment amount you received for a service is less than the amount indicated in the Medicare Advantage terms and conditions of payment, you have the right to dispute the payment amount by following Medicare Advantage dispute resolution process. Services denied for coverage issues such as Local Coverage Determinations, National Coverage Determinations, or medical necessity are generally not subject to this payment dispute resolution process.
To file a payment dispute with Arkansas Blue Medicare and/or Health Advantage, send a written dispute to Arkansas Blue Medicare and/or Health Advantage:
Legal Appeals Department
P.O. Box 2181
Little Rock, AR 72203
Additionally, please provide appropriate documentation to support your payment dispute (e.g., a remittance advice from a Medicare carrier would be considered such documentation). Claims must be disputed within 120 days from the date payment is initially received by the provider. Note that in cases where Arkansas Blue Medicare and/or Health Advantage re-adjudicates a claim, for instance, when Arkansas Blue Medicare and/or Health Advantage discovers the claim was processed incorrectly the first time, you have an additional 120 days from the date you are notified of the re-adjudication in which to dispute the claim.
Arkansas Blue Medicare and/or Health Advantage will review your dispute and respond to you within 30 days from the time the provider payment dispute is first received by Arkansas Blue Medicare and/or Health Advantage. If Arkansas Blue Medicare and/or Health Advantage agrees with the reason for your payment dispute, Arkansas Blue Medicare and/or Health Advantage will pay you the additional amount you are requesting, including any interest that is due. Arkansas Blue Medicare and/or Health Advantage will inform you in writing if the decision is unfavorable and no additional amount is owed.
Arkansas Blue Medicare and/or Health Advantage members have the right to file appeals and grievances with Arkansas Blue Medicare and/or Health Advantage when they have concerns or problems related to coverage or care. Members may appeal a decision made by Arkansas Blue Medicare and/or Health Advantage to deny coverage or payment for a service or benefit that they believe should be covered or paid for. Members should file a grievance for all other types of complaints not related to the provision or payment for health care.
Providers and/or physicians also have certain appeal opportunities under the Member Appeal process. Those opportunities are set forth below.
A Contracting or Non-Contracted Physician who is providing treatment may, upon notifying the member, appeal pre-service organization determination denials to the plan on behalf of the member without submitting an Appointment of Representative form or Waiver of Liability Form. Arkansas Blue Medicare and/or Health Advantage is required by Medicare to verify that the member has been notified and approves of the physician’s appeal request. If Arkansas Blue Medicare and/or Health Advantage verifies the Member’s knowledge of the physician’s request, it will be processed according to the Medicare Advantage five-level member appeal process.
Arkansas Blue Medicare and/or Health Advantage automatically grants an expedited appeal if any physician or other provider, whether participating with Arkansas Blue Medicare and/or Health Advantage or not, asks for one on the grounds that waiting for a standard appeal could seriously jeopardize the member’s life, health or ability to regain maximum function or, in the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment being requested. An expedited appeal will not be granted for a service that has already been provided.
A contracting physician or contracting provider may also request review of a post-service organization determination denial as a representative using the Member appeal process. To do so, the physician should include an Appointment of Representative form with the appeal submission.
A non-contracting physician or provider may appeal a post-service determination using the member appeal process by signing a waiver of liability. This form can be found at https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms . When the physician or other provider signs the form, he or she agrees not to bill the member regardless of the outcome of the appeal. The waiver of liability should be included with the appeal submission. Medicare regulations prohibit Arkansas Blue Medicare and/or Health Advantage from considering the appeal until the signed Waiver of Liability form is received. When Arkansas Blue Medicare and/or Health Advantage receives the signed form, the appeal is processed according to the Arkansas Blue Medicare and/or Health Advantage five-level member appeal process.
If a provider appeals using the member appeal process, the provider agrees to abide by the statutes, regulations, standards, and guidelines applicable to the Medicare Member appeals and grievance processes. Included in these regulations is the requirement that the appeal be submitted within 60 days from the date on the denial notice.
The Arkansas Blue Medicare and/or Health Advantage Member Evidence of Coverage (EOC) provides more detailed information about the member appeal and grievance processes. The member EOC is posted under the Arkansas Blue Medicare and/or Health Advantage link on the website located at: http://www.arkbluecross.com
You can call Customer Service at 1-844-373-0975 for more information on our member appeals and grievance policies and procedures.
Contracting providers with Arkansas Blue Medicare and/or Health Advantage have dispute resolution rights outside of the member appeals process. Specifically, a Contracted Physician or Contracted Provider may request a review of a post-service denial related to medical necessity or medical appropriateness. A Contracted Physician or Provider may also request a review of administrative denials. Administrative denials are determinations made by Arkansas Blue Medicare and/or Health Advantage in accordance with administrative policies and procedures and/or contract language. These determinations are not based on medical necessity or appropriateness. Examples of administrative denials include, but are not limited to: (1) Provider noncompliance with clinical review requirements for elective procedures requiring Arkansas Blue Medicare and/or Health Advantage approval; and (2) Provider noncompliance with providing clinical information needed to render a decision for inpatient admissions within 48 hours of Arkansas Blue Medicare and/or Health Advantage’s request. Finally, a contracting provider may request a review when he or she believes that the payment amount made by the Arkansas Blue Medicare and/or Health Advantage plan to the contracted provider is less than the payment amount that would have been paid under the Medicare fee schedule.
Arkansas Blue Medicare and/or Health Advantage assumes that the physician or provider is acting on his or her own behalf. Submission of an Appointment of Representative form is not required for these review requests as they are not considered a part of the CMS regulated member appeal process.
These post-service review requests will be reviewed based on:
A single level of review will be provided. This review process is designed to be objective, thorough, fair and timely.
When a Provider Claim Adjudication Review Request is received and a member appeal is in process, the member appeal takes precedence. When the member appeal process is complete, the member appeal decision is considered to be final and the provider review request will not be separately processed.
For payment amount disputes, the review request must be submitted within 120 days from the date the payment is initially received. For all other review requests, the request must be submitted to Arkansas Blue Medicare and/or Health Advantage within 60 calendar days of the date noted on the written denial notification. If the review request is received by Arkansas Blue Medicare and/or Health Advantage outside the designated time frame, Arkansas Blue Medicare and/or Health Advantage is not obligated to review the case. A letter will be sent to the requesting provider either advising that the request was not reviewed or notifying the physician of the outcome of the request if the plan has chosen to review the case.
Requests are to be in writing and must include any additional clarifying clinical information to support the request. Please identify the submission as a Provider Claim Adjudication Review Request. Appropriate documentation needed for a medical necessity review includes:
Arkansas Contracting Provider/Physician Post-Service Review Requests should submit these requests to:
If Arkansas Blue Medicare Legal Appeals Department
Attn: Contracting Provider Claim Adjudication Review Request
P.O. Box 2181
Little Rock, AR 72203
If Health Advantage Legal Appeals Department
Attn: Contracting Provider Claim Adjudication Review Request
P.O. Box 2181
Little Rock, AR 72203
Non-Arkansas Contracting providers should submit these requests to your local Blue Plan.
Arkansas Blue Medicare and/or Health Advantage will notify the provider of the decision within 30 calendar days of receiving all necessary information.
Only one level of review will be provided. The decision regarding the review is final.
Hospitals must notify Medicare beneficiaries, including Medicare Advantage beneficiaries enrolled in PFFS plans, who are hospital inpatients about their discharge appeal rights by complying with the requirements for providing the Important Message from Medicare (IM), including complying with the normal time frames for delivery. For copies of the notice and additional information regarding this requirement, go to: http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp
Skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities must notify Medicare beneficiaries, including Medicare Advantage beneficiaries enrolled in PFFS plans, about their right to appeal a termination of services decision by complying with the requirements for providing the Notice of Medicare Non-Coverage (NOMNC), including complying with the normal time frames for delivery. For copies of the notice and the notice instructions, go to: http://www.cms.gov/BNI/09_MAEDNotices.asp
As directed in the instructions, the NOMNC should contain the Medicare Advantage contact information somewhere on the form (such as in the additional information section on page 2 of the NOMNC).
Hospitals, home health agencies, comprehensive outpatient rehabilitation facilities, or skilled nursing facilities must provide members with a detailed explanation on behalf of the plan if a member notifies the Quality Improvement Organization (QIO) that the member wishes to appeal a decision regarding a hospital discharge (Detailed Notice of Discharge) or termination of home health agency, comprehensive outpatient rehabilitation facility or skilled nursing facility services (Detailed Explanation of Non-coverage) within the time frames specified by law. For copies of the notices and the notice instructions, go to: http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp and http://www.cms.gov/BNI/09_MAEDNotices.asp
If you have general questions about the Medicare Advantage terms and conditions of payment, contact us at 877-233-7022, Monday – Friday, 8 a.m. to 8 p.m. or mail us at Medicare Advantage, P.O. Box 2181, Little Rock, AR 72203-2181.
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