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The BlueCard Program
Filing Claims - Medicare Advantage

Medicare Advantage (MA) is the program alternative to standard Medicare Part A and Part B fee-for-service coverage, generally referred to as Original Medicare.

MA offers Medicare beneficiaries several product options, including:

  • Point-of-service (POS)
  • Private-fee-for-service (PFFS)
  • Preferred Provider Organization (PPO)
  • Health Maintenance Organization (HMO)

Medicare Advantage is a separate program from BlueCard. However, like claims for BlueCard members, claims for Regence MedAdvantage members should be sent to Regence.

Note for institutional providers that have subparts (e.g., psychiatric unit, rehabilitation):
When submitting Medicare Advantage claims, you are required to submit a taxonomy code on electronic and paper claims. Institutional claims received without this information will be denied. The provider will then have to resubmit the claim with the taxonomy code..

Point-of-service (POS)

A Medicare Advantage POS program is an option available through some Medicare HMO programs. It allows members to determine, at the point of service, whether they want to receive certain designated services within the HMO system, or seek services outside the HMO’s provider network (usually with greater cost to the member). The Medicare Advantage POS plan may specify which services will be available outside of the HMO’s provider network.

Since the level of benefits and coverage rule vary, verify eligibility and benefits for these members prior to rendering services.

Private Fee-for-Service (PFFS)

If you are providing services for a patient with a Medicare Advantage Private Fee-for-Service (PFFS) plan, you can access the Medicare Advantage PFFS terms and conditions using the Web Finder Tool. Although Regence does not offer a PFFS plan, other Blue Cross and/or Blue Shield Plans (Blue Plans) do, and their members may seek services in Washington.

  • Submit claims to Regence.
  • Reimbursement is paid at the Home plan contracted rate or Medicare rate, depending on the member contract. 
Medical Savings Account (MSA)

A Medicare Advantage MSA plan is made up of two parts. One part is the Medicare Medical Savings Account (MSA) which is a type of savings account for members to pay for qualified medical expenses.  The other part is the Medicare MSA Health Policy that is a special health insurance policy with a high deductible. Qualified medical expenses are services and products that otherwise could be deducted as medical expenses on the member’s annual tax return, which includes but is not limited to doctor visits, hospital stays, dental exams and medical equipment. The Blue Plan calculates the amount and the Medicare program deposits the funds into the member’s savings account. Savings balances accumulate interest or dividends tax free until spent and as long as the member spends the funds on qualified medical expenses, the money is tax free to the member. 

  • Submit claims to Regence.
  • Reimbursement is paid at the Home plan contracted rate or Medicare rate, depending on the member contract. 
PPO Network Sharing

Network sharing allows Medicare Advantage (MA) PPO members from MA PPO Blue Plans to obtain in-network benefits when traveling or living in the service areas of the MA PPO Plans, as long as the member sees a contracted Medicare Advantage PPO provider.

If you are a Regence MedAdvantage PPO provider and see MA PPO members from other Blue Plans, these members must be guaranteed access to care and receive in-network benefits in accordance with their member contract.

  • Submit claims to Regence
  • Reimbursement is paid at your Regence MedAdvantage contracted rate
If you are not a Regence MedAdvantage PPO provider and see MA PPO members from other Blue Plans, you will receive the Medicare allowed amount (not Regence MedAdvantage allowable) for covered services. These services will be paid under the member’s out-of-network benefit level (benefits may vary), unless services were for urgent or emergent care.
Health Maintenance Organization (HMO)

A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals. Generally (except in urgent or emergent situations), medical services are only covered when provided by in-network providers.

Since the level of benefits and coverage rule vary, verify eligibility and benefits for these members prior to rendering services.

Medicare Crossover claims

If you accept Medicare assignment and render services to Medicare beneficiaries with coverage from other Blue Plans (e.g., Medigap plans), learn more about Medicare Crossover claims.

Medicare Statutorily Excluded Services

If you provide services to patients that are statutorily excluded by Medicare (e.g., home infusion therapy and hearing aids), submit only those services to your local Blue Plan, Regence.