Billing members

Collect copayments or coinsurance at time of service

The member is responsible for cost-sharing amounts and you may collect them at the time of service.

 

Balance billing is not allowed

You may collect only applicable cost-sharing from Medicare Plus Blue PFFS^SM members and may not otherwise charge or bill them.

 

Noncovered services

Sometimes you and your patient may decide that a service or treatment is the best course of care, even though it isn't covered by Medicare Plus Blue PFFS.

 

If you believe that a service won't be covered, you need to tell the member before the service is performed. If the member acknowledges that it won't be covered by Medicare Plus Blue and agrees that he or she will be solely responsible for paying you, you may perform and bill the member for the noncovered service. This decision is between you and your patient, and the process is called notification of noncoverage.

 

We encourage you to give the notification and obtain acknowledgement in writing, although Centers for Medicare & Medicaid Services does not require documentation on a specific form.

 

Refund over-billed members

If you collect more from a member than the applicable cost-sharing, you must refund the difference.

 

Coordination of benefits

If a member has primary coverage with another plan, submit a claim for payment to that plan first. The amount we will pay depends on the amount paid by the primary plan. We follow all Medicare secondary-payer laws.