April 5, 2006

BC-06-07
HP-06-05
SA-06-05

HHA-06-05
DC-06-05

Medicare Advantage Programs Offered By Blue Cross and Blue Shield Plans – UPDATE

Medicare Advantage is a program alternative that some beneficiaries may choose in place of traditional Medicare Part A and Part B fee-for-service coverage.

While Blue Cross and Blue Shield of Kansas has chosen not to develop a Medicare Advantage product, other Blue Plans have and it is likely that these members will receive medical services from BCBSKS contracting providers. 

When this occurs, your processes should be the same as those used when treating any out-of-area BCBS member.

• Ask for the members ID card – the card will clearly identify the member as a Medicare Advantage member and will include the BCBS logo.  This card will not look like a standard Medicare card.
• Verify the member's eligibility by calling 1-800-676-BLUE (2583). 
• Submit the claim to BCBSKS.  

After BCBSKS receives the claim:

• Details about the claim (services provided, charges, etc.) will be given to the other BCBS plan.
• The other plan will adjudicate the claim and advise BCBSKS of the allowance and member responsibility.  The Medicare Advantage allowance is based on the Centers for Medicare & Medicaid Services (CMS) regulations and in this situation is generally an amount equivalent to Medicare allowances.
• BCBSKS will finalize the payment and report the information on the BCBSKS remittance advice.

After a claim is finalized, if you have reason to appeal the claim on behalf of the member, you should deal directly with the out-of-state BCBS plan.  The other BCBS plan will make the final appeal determination.

drb