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Medicare Advantage Terms & Conditions

Table of contents

  1. Introduction
  2. Special Rules for Private Fee-For-Service Members
  3. Provider Networks
  4. Provider Qualifications and Requirements.
  5. Payment to Providers:
  6. Filing A Claim for Payment.
  7. Maintaining Medical Records and Allowing Audits.
  8. Getting An Advance Organization Determination.
  9. Contracted Provider Payment Dispute Resolution Process
  10. Member And Non-Contracted Provider Appeals and Grievances and Contracted Provider Payment Dispute Resolution Under the Member Appeal Process.
  11. Providing Members with Notice of Their Appeal Rights – Requirements for Hospitals, SNFs, CORFs And HHAs.
  12. If You Need Additional Information or Have Questions.

1. Introduction

Section 2 of this Manual explains the special rules for non-contracted providers who agree to treat Arkansas Blue Medicare PFFS members. The rest of this document explains the contractual and regulatory provisions that govern the relationship between you and Arkansas Blue Medicare and/or Health Advantage.

2. Special Rules for Private Fee-For-Service Plans

Arkansas Blue Medicare offers a Private Fee-for-Service (PFFS) plan. Unlike HMO or PPO plans, the PFFS plan allows members to use any provider, such as a physician, health professional, hospital, or other Medicare provider in the United States under certain circumstances. If the provider: 1) reviews and accepts the Medicare PFFS terms and conditions of payment: 2) agrees to treat the patient; and 3) is eligible to provide health care services under Medicare Part A and Part B (also known as "Original Medicare") OR is eligible to be paid by Arkansas Blue Medicare for benefits that are not covered under Original Medicare, then the provider is “deemed” to accept the PFFS Terms and Conditions and may be reimbursed by Arkansas Blue Medicare PFFS for plan-covered services.

Note: You can decide whether or not to accept the PFFS Medicare Advantage terms and conditions of payment each time you see an Arkansas Blue Medicare PFFS member. A decision to treat one PFFS plan member does not obligate you to treat other Medicare Advantage PFFS members, nor does it obligate you to treat the same PFFS member at subsequent visits.

If you DO NOT wish to accept the Medicare Advantage terms and conditions of payment, then you should not furnish services to an Arkansas Blue Medicare PFFS member, except for emergency services. If you elect to furnish non-emergency services to an Arkansas Blue Medicare PFFS member, you will be subject to the PFFS terms and conditions of payment whether you wish to agree to them or not. Providers furnishing emergency services will be treated as non-contracted providers and paid at the payment amounts they would have received under Original Medicare.

PFFS plans also have different rules for referrals and prior authorizations than HMO and PPO plans. No prior authorization, prior notification or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to a PFFS member. However, a PFFS member or his or her 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 PFFS plan. Section 7 describes how a provider can request an advance organization determination from the plan.

3. Provider Networks

Arkansas Blue Medicare and/or Health Advantage has signed contracts with many providers. These providers are our network providers.

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).

Members of an Arkansas Blue Medicare or Health Advantage plan will have a member ID card that includes either the Arkansas Blue Medicare or Health Advantage logo that clearly identifies the patient as a member of either Arkansas Blue Medicare (HMO/PPO/PFFS) or Health Advantage Medicare Advantage HMO. You may validate eligibility by calling Customer Service at 800-287-4188. In addition, providers may check Availity to verify member eligibility.

Providers may request a copy of, or have reasonable access to, the Medicare Advantage terms and conditions of payment (this document) found on our website at: www.arkansasbluecross.com and/or www.arkbluemedicare.com.

The terms and conditions may also be obtained by calling Customer Service 800-287-4188.

4. Provider Qualifications and Requirements

In order to be paid by Arkansas Blue Medicare and/or Health Advantage for services provided to one of our members, you must:

  • Have a National Provider Identifier in order to submit electronic transactions to Arkansas Blue Medicare and/or Health Advantage, in accordance with HIPAA requirements.
  • Submit all claims (electronic or paper) to your local Blue plan. Please note: Out-of-state services and coverage vary based on the members benefits and plan coverage.
  • Furnish services to an Arkansas Blue Medicare and/or Health Advantage member within the scope of your licensure or certification.
  • Provide only services that are covered by the Arkansas Blue Medicare and/or Health Advantage plan and are medically necessary by Medicare definitions.
  • Meet applicable Medicare certification requirements (e.g., if you are an institutional provider such as a hospital or skilled nursing facility).
  • Not have opted out of participation in the Medicare program under §1802(b) of the Social Security Act, unless providing emergency or urgently needed services.
  • Not be on the HHS Office of Inspectors General excluded and sanctioned provider list.
  • Not be on the Medicare Preclusion List.
  • Not be a federal health care provider, such as a Veterans' Administration provider, except when providing emergency care.
  • Comply with all applicable Medicare and other applicable federal health care program laws, regulations, and program instructions, including laws protecting patient privacy rights and HIPAA that apply to covered services furnished to members.
  • Agree to cooperate with Arkansas Blue Medicare and/or Health Advantage to resolve any member grievance involving the provider within the time frame required under Federal law.
  • For providers who are hospitals, home health agencies, skilled nursing facilities, or comprehensive outpatient rehabilitation facilities, provide applicable beneficiary appeals notices (See Section 10 for specific requirements).
  • Network providers should not charge the member in excess of cost sharing allowed under these Terms and Conditions under any condition, including in the event of plan bankruptcy.

5. Payments to Providers

Plan Payment

Arkansas Blue Medicare and/or Health Advantage reimburses network 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 network physicians who would have received them in connection with treating Medicare beneficiaries who are not enrolled in the Arkansas Blue Medicare and/or Health Advantage plan.

Arkansas Blue Medicare and/or Health Advantage will process and pay clean claims within 30 days of receipt from in-network providers. 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 6 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 Medicare 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 1-800-287-4188 to receive information on our fee schedule.

Network providers furnishing such services must accept the fee schedule amount, minus applicable member cost sharing, as payment in full.

Member Benefits and Cost Sharing

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-payment or coinsurance amount 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.

To view a complete list of covered services and member cost sharing amounts under Arkansas Blue Medicare and/or Health Advantage go to: https://www.arkansasbluecross.com/medicare/medicare-forms.

You may call us at 800-287-4188 to obtain more information about covered benefits, plan payment rates, and member cost sharing amounts under the member’s specific Medicare Advantage plan. Be sure to have the member's ID number, including the 3-character alpha prefix (on the ID card), when you call.

Arkansas Blue Medicare and Health Advantage follow Medicare coverage decisions for Medicare-covered services. Services not covered by Medicare are not covered by Arkansas Blue Medicare and Health Advantage, unless specified by the plan. Information on obtaining an advance organization determination can be found in Section 8. BlueMedicare PFFS does not require members or providers to obtain prior authorization, prior notification or referrals from the plan as a condition of coverage. Arkansas Blue Medicare PPO, Arkansas Blue Medicare HMO and Health Advantage plans may require prior authorization and prior notification based on certain specified services.

Note: Medicare supplemental policies, commonly referred to as Medigap plans, cannot cover cost sharing amounts for Medicare Advantage plans, including Arkansas Blue Medicare and Health Advantage plans. All cost sharing is the member's responsibility.

Balance Billing of Members

A provider may only collect the applicable plan cost sharing amounts from Arkansas Blue Medicare and Health Advantage members. Anything over the allowed amount, minus member cost sharing amounts, must be written off by the provider.

Hold Harmless Requirements

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 network 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.

6. Filing a Claim for Payment

You must submit a claim to Arkansas Blue Medicare and/or Health Advantage for an Original Medicare covered service within the same time frame you would have to submit under Original Medicare, which is within one calendar year after the date of service. Failure to be timely with claim submissions may result in non-payment. The rules for submitting timely claims under Original Medicare can be found at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R697OTN.pdf

Prompt Payment— 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, Arkansas Blue Medicare and/or Health Advantage will pay interest on the claim according to Medicare guidelines. A clean claim includes the minimum information necessary to adjudicate a claim, not to exceed the information required by Original Medicare. Arkansas Blue Medicare and/or Health Advantage will process all non-clean claims and notify providers of the determination within 60 days of receiving such claims.

Submit claims using the standard CMS-1500, CMS-1450 (UB-04), or the appropriate electronic filing format.

Use the same coding rules and billing guidelines as Original Medicare, including Medicare CPT Codes, HCPCS codes and defined modifiers. Bill diagnosis codes to the highest level of specificity.

7. Maintaining Medical Records and Allowing Audits

All 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.

All 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.

8. Getting an Advance Organization Determination

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 800-287-4188 or send by fax to 1-816-313-3014. Arkansas Blue Medicare and/or Health Advantage will make a decision and notify you and the member within 14 calendar days of receiving the request, with a possible 14-day extension, either due to the member's request or an 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 800-287-4188 or send by fax to 1-816-313-3014 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 (24 hours after receiving the expedited request for Part B drugs), unless we invoke a 14-day extension either at the member's request or if Arkansas Blue Medicare and/or Health Advantage has justification (for example, the receipt of additional medical evidence that may affect the decision or outcome) that the delay is in the member's best interest.

In the absence of an approved 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, non-contracted providers have the right to dispute our decision by exercising their appeals rights (see the Federal regulations at 42 CFR Part 422, subpart M, or combined Chapters 13 and 18 of the Medicare Managed Care Manual). Non-contracted provider appeals must be submitted with a signed Model Waiver of Liability form found on CMS website at https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms.

9. Contracted Provider Payment Dispute Resolution Process

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 the Medicare Advantage Provider Payment 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, contracted providers should send a written dispute to Arkansas Blue Medicare and/or Health Advantage:

Additionally, please provide any 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 adjusts (or reprocesses) a previously processed 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 adjustment in which to dispute the payment.

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. 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 of the decision.

10. Member and Non-Contracted Provider Appeals and Grievances and Contracted Provider Payment Dispute Resolution Under the Member Appeal Process

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 may file a grievance for any dissatisfaction related to the operations, activities or behavior of Arkansas Blue Medicare and/or Health Advantage or our delegated entities (i.e.: contracted providers) in the provision of health care items, services, or prescription drugs, regardless of whether remedial action is requested or can be taken.

Providers and/or physicians also have certain appeal opportunities under the Member Appeal process. Those opportunities are set forth below.

A. Pre-Service Appeal Request

A contracted or non-contracted physician who is providing treatment to an Arkansas Blue Medicare member or Health Advantage member 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 will undertake reasonable efforts to confirm that the member has received appropriate notification if the member’s records do not indicate that he or she has been previously treated by the requesting physician. If Arkansas Blue Medicare and/or Health Advantage verifies the member is aware of the physician’s request, it will be processed according to the Medicare Advantage enrollee appeal process.

Arkansas Blue Medicare and/or Health Advantage will automatically process an appeal as expedited if a 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.

B. Post-Service Appeal Request

A contracted physician or provider who is providing treatment to an Arkansas Blue Medicare member or Health Advantage member may, upon notifying the member, appeal post-service organization determination denials (or denied claims) to the plan on behalf of the member without submitting an Appointment of Representative form. Arkansas Blue Medicare and/or Health Advantage will undertake reasonable efforts to confirm that the member has received appropriate notification if the member’s records do not indicate that he or she has been previously treated by the requesting physician. If Arkansas Blue Medicare and/or Health Advantage verifies the member is aware of the physician’s request, the denied claim will be processed according to the Medicare Advantage enrollee appeal process.

A non-contracted physician or provider may appeal a post-service organization determination (a denied claim) using the appeal process by signing and submitting a Waiver of Liability form along with the request to appeal the denied claim. 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 must 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 Medicare enrollee appeal process.

If a provider submits an appeal on behalf of a member, using the member appeal process, the provider agrees to abide by the statutes, regulations, standards, and guidelines applicable to the Medicare enrollee appeals process. 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: https://www.arkansasbluecross.com/medicare

You can call Customer Service at 1-877-233-7022 for more information on the Medicare Advantage appeals process.

11. Providing Members with Notice of Their Appeals Rights – Requirements For Hospitals, SNFs, CORFs and HHAs

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: https://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: https://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: https://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp and https://www.cms.gov/BNI/09_MAEDNotices.asp.

12. If You Need Additional Information or Have Questions

If you have any questions about the Medicare Advantage terms and conditions of payment, contact us at 800-287-4188, Monday – Friday, 8 a.m. to 8 p.m. or mail us at Arkansas Blue Medicare and Health Advantage, P.O. Box 3648, Little Rock, AR 72203-3648.

If you have questions about submitting claims, call 501-378-2336.

If you have questions about plan payments, call 1-877-359-1441.