What is BCBS Medicare Advantage (MA) PPO Network Sharing?

Beginning January 1, 2010, all Blue Medicare Advantage PPO Plans will participate in reciprocal network sharing. This network sharing will allow all Blue Medicare PPO members to obtain in-network benefits when traveling or living in the service area of any other Blue MA PPO Plan as long as the member sees a contracted MA PPO provider.

What does the BCBS Medicare Advantage PPO Network Sharing mean to me?

If you are a contracted Blue Medicare PPO provider with BCBSTX and you see MA PPO members from other Blue Plans, you will be reimbursed in accordance with the then current Blue Medicare PPO fee schedule. The members will receive in-network benefits in accordance with their member contract. 

If you are not a contracted Blue Medicare PPO provider with BCBSTX and you provide services for any Blue Medicare Advantage members, you will receive the Medicare allowed amount for covered services.  For Urgent or Emergency care, you will be reimbursed at the member’s in-network benefit level.  Other services will be reimbursed at the out-of-network benefit level.

How do I recognize an out-of-area member from one of these Plans participating in the BCBS MA PPO network sharing?

The “MA” in the suitcase indicates a member who is covered under the MA PPO network sharing program. Members have been asked not to show their standard Medicare ID card when receiving services; instead, members should provide their Blue Cross and/or Blue Shield member ID. 

Do I have to provide services to Medicare Advantage PPO members from these other Blue Plans?

If you are a contracted Blue Medicare PPO provider with BCBSTX, you should provide the same access to care as you do for BCBSTX Blue Medicare PPO members and can expect to receive the same contracted rates for such services beginning January 1, 2010.

If you are not a Blue Medicare PPO contracted provider, you may see Blue Medicare Advantage members but you are not required to do so. Should you decide to provide services to Blue Medicare Advantage members, you will be reimbursed for covered services at the Medicare allowed amount based on where the services were rendered and under the member’s out-of-network benefits.  For Urgent or Emergency care, you will be reimbursed at the in-network benefit level.

What if my practice is closed to new local Blue Medicare PPO members?

If your practice is closed to new local Blue Medicare PPO members, you do not have to provide care for Blue MA PPO out-of-area members.  The same contractual arrangements apply to these out-of-area network sharing members as your local Blue Medicare PPO members.

How do I verify benefits and eligibility?

Call BlueCard Eligibility at 1.800.676.BLUE (2583) and provide the member’s alpha prefix located on the ID card.

Where do I submit the claim?

You should submit the claim to BCBSTX under your current billing practices. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.

What will I be paid for providing services to these out-of-area Medicare Advantage PPO network sharing members?

If you are a Blue Medicare PPO contracted provider with BCBSTX, reimbursement will be based on your contracted Blue Medicare PPO rate for providing covered services to MA PPO members from any MA PPO Plan. Once you submit the MA claim, BCBSTX will work with the other Plan to determine benefits and send you the payment. 

What will I be paid for providing services to other Medicare Advantage out-of-area members not participating in the Medicare Advantage PPO Network Sharing?

When you provide covered services to other Medicare Advantage PPO out-of-area members not participating in network sharing, reimbursement will be based on the Medicare allowed amount.  Once you submit the MA claim, BCBSTX will send you the payment.  However, these services will be paid under the member’s out-of-network benefits unless for urgent or emergency care.

What is the member cost sharing level and co-payments?

MA PPO members who see Blue Medicare PPO contracted providers in Texas will pay the same cost sharing level (in-network cost sharing) they would pay if they received covered benefits from any MA PPO in-network provider.  You may collect the co-payment amount from the member at the time of service.

May I balance bill the member the difference in my charge and the allowance?

No, you may not balance bill the member for this difference. Members may be billed for any deductibles, co-insurance, and/or co-pays.  

What if I disagree with the reimbursement amount I received?

If there is a question concerning the reimbursement amount, contact Provider Customer Service at 1-800-451-0287

Who do I contact if I have a question about MA PPO network sharing?

If you have any questions, please call 713-354 -1149 or 1-800-637-0171 in the Houston/Beaumont area; or 915-496-6600 or 1-800-862-6789 in the El Paso area.

posted 5/2009