“Medicare Advantage” is the new program alternative to standard Medicare Part A and Part B fee-for-service coverage (generally referred to as “traditional Medicare”). It offers Medicare beneficiaries several product options, including health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS) and private fee-for-service (PFFS) plans. Several Blue Plans offer Medicare Advantage products, so you may see out-of-area Medicare Advantage members.
What is Medicare Advantage Private Fee for Service?
A Medicare Advantage PFFS plan is a plan offered by an organization that pays physicians and providers on a fee-for-service basis. There is no specific network that providers sign up for to service PFFS patients. Patients can obtain services from any licensed physician or provider in the United States who is qualified to be paid by Medicare and accepts the plan’s terms of payment. The Plan must provide the same coverage as Medicare Part A and Part B, but may offer additional services.
How to recognize Medicare Advantage PFFS members?
Ask for the member ID card. Members will not have a standard Medicare card; instead, they will carry a Blue Cross and/or Blue Shield ID card with this logo:
How to verify member eligibility?
Verify eligibility by calling 1-800-676-Blue (2583) and providing the alpha prefix or electronically at www.bcbsks.com. Be sure to verify if Medicare Advantage benefits apply. If you experience difficulty obtaining eligibility information, please record the alpha prefix and report it to the BCBSKS customer service center.
Where to submit claims for Medicare Advantage PFFS members?
Submit claims to BCBSKS. Do not bill Medicare directly for any services rendered to a Medicare Advantage member. Payment will be made directly by a Blue Plan.
What reimbursement rates apply for PFFS patients?
You will be reimbursed the equivalent of the current Medicare payment amount for all covered services (i.e. the amount you would collect if the member was enrolled in traditional Medicare.) Refer to the member ID card for instructions on how to access terms and conditions.
Can I collect member cost sharing amount at the time of service?
Yes, providers can collect any applicable cost sharing amount (i.e. copay, deductible). Balance billing may be permitted under some PFFS plans, so refer to the member ID card for instructions on how to access terms and conditions.
Make a note of these important things about MA PFFS, as this product varies from the other Blue products you might currently participate in:
- You can see and treat any Medicare Advantage PFFS member without having a contract with BCBSKS.
- If you do provide services, you will do so under the Terms and Conditions of that member’s Blue Plan.
- Please refer to the back of the member’s ID card for information on accessing the Plan’s Terms and Conditions. You may choose to render services to a MA PFFS member on an episode of care (claim-by-claim) basis.
- MA PFFS Terms and Conditions might vary for each Blue Cross and/or Blue Shield Plan and we advise that you review them before servicing MA PFFS members.
- Submit your MA PFFS claims to BCBSKS.
- Coming in 2008, MA PFFS Terms and Conditions for all Blue Plans and accessed based on the member's 3-letter alpha prefix will be available through the BCBSKS Web site. More details will be furnished once this information is available.
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