AAPC - Back to school
Results 1 to 3 of 3

Thread: Medicare Replacement Plans

  1. #1

    Default Medicare Replacement Plans

    AAPC: Back to School
    For billing Medicare Replacement Plans (HMO's, etc), are offices required to utilize the Medicare fee schedule for those covered services or since Medicare Replacement Plans are outside Medicare jurisdiction, are those offices allowed to bill at their standard fees? If anyone has the answer to this that would be excellent. Also, I am hoping for a written reference for my records, if you know where that can be found.

    Thank you.

  2. #2
    Join Date
    Apr 2007


    On the back of some of those plan's ID cards it has verbiage about if a doctor agrees to see the patient it "deems" the provider to accept their fee as payment in full (& not balance bill the patient).

    Maybe others will have more info about the plans & what is/isn't allowed when it comes to billing the patient....

  3. #3


    Your contract with each particular plan should indicate which rules you should follow. First refer back to your contract. Where we are (St. Louis area) most of the Medicare Advantage plans do follow Medicare's guidelines because these patients are still Medicare eligible patients. For example, one of our payers has a commercial line as well as a Medicare Advantage plan. The payer rules are different depending on whether the patient is under the commercial plan (consult codes can be billed) or the Advantage plan (consult codes cannot be billed). I don't have the link to the CMS website but I believe there is a section that addresses this issue.

Similar Threads

  1. KX modifer for Humana Medicare Replacement plans
    By jennifersellards@hotmail.com in forum Modifiers
    Replies: 0
    Last Post: 09-11-2014, 11:32 AM
  2. Medicare Replacement Plans
    By pglazener in forum Billing/Reimbursement
    Replies: 3
    Last Post: 02-02-2012, 06:48 AM
  3. Medicare Replacement Plans
    By penguins11 in forum Medicare Regulations
    Replies: 3
    Last Post: 01-16-2012, 02:26 PM
  4. Medicare Replacement Plans
    By dcarr in forum Pathology & Clinical Laboratory
    Replies: 0
    Last Post: 09-29-2009, 03:33 PM
  5. Medicare replacement plans?
    By moricecrys in forum Medicare Regulations
    Replies: 3
    Last Post: 04-14-2009, 09:00 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.