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Thread: Medicare replacement plans?

  1. #1

    Question Medicare replacement plans?

    AAPC: Back to School



  2. #2
    Join Date
    Apr 2007
    North Carolina


    My understanding is "no"...

    It is important to emphasize that although a provider who does not have a direct contract with the plan may choose to provide, or not to provide services, the provider does not have the option of becoming non-contracting. Rather, once the provider provides services, the provider automatically becomes deemed-contracting provided the deeming conditions listed above have been met.
    EXAMPLES: The following examples illustrate typical situations in which the provider becomes deemed contracting.

    • An enrollee walks into a physician’s office for the first time, advises the physician that he or she is a member of the PFFS plan and presents his or her plan enrollment card. Since the provider had the opportunity to call the plan phone number on the enrollee card, the provider is considered deemed contracting as soon as s/he provides services, even though the provider did not actually check the terms and conditions of payments.
    • An enrollee enters a hospital for non-emergency care, advises the hospital that he or she is a member of the PFFS plan and presents his or her plan enrollment card. All providers that contract with this hospital, or are employed by this hospital, are considered deemed contracting as soon as they provide services, even though hospital providers typically do not themselves verify plan enrollment.

    The following examples illustrate when a provider is considered non-contracting:

    • A provider who provides care in an emergency to an unconscious enrollee is noncontracting if the provider did not know prior to furnishing services that the enrollee belonged to a PFFS plan;
    • A provider who, prior to furnishing services, did not have reasonable access to the PFFS plan’s terms and conditions of payment, is also considered non-contracting


    section 150~

  3. #3
    Join Date
    Apr 2007
    Hartford, CT


    This only applies to Private Fee For Service Plans (states PFFS on card). Otherwise the plans work just like an HMO and you have to be contracted, for instance in CT we have Wellcare, Healthnet and Mediblue (Anthem). These are all HMO plans not PFFS plans, we must have a contract with them to get paid, or the patient must get prior auth from their PC and the plan to see our cardiologists. It is very importanat to know ahead of time which plan the patient has, unfortunately many patients don't have a clue as to what they signed up for.


  4. #4


    Thank you so much !

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