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2010 Medicare BlueSM Private-Fee-For-Service Plans

DEEMED PROVIDERS Definition

Providers will be considered "deemed" contract providers in accordance with 42 USC 422 if:

  1. The Provider has knowledge that a Medicare beneficiary is a member of the BlueCross BlueShield of South Carolina Medicare Advantage Health Plan.
  2. The information on the BlueCross BlueShield of South Carolina Medicare Advantage Health Plan’s Terms and Conditions of Participation (T&C) is reasonably available to the Provider through multiple means and the Provider has an opportunity to obtain this information before treating the BlueCross BlueShield of South Carolina Medicare Advantage Health Plan Member.
  3. The Provider then renders care to the BlueCross BlueShield of South Carolina Health Plan Member.
  4. Once the above has been accomplished, the Provider is considered "deemed" and will be subject to the BlueCross BlueShield of South Carolina Health Terms and Conditions of Participation.

Terms and Conditions

Under the BlueCross BlueShield of South Carolina Health Private Fee-For-Service Plan, enrollees can see any willing Medicare-eligible provider. In general, the BlueCross BlueShield of South Carolina Health Plan’s Terms and Conditions of Participation include:

  • The Provider must be licensed or certified in the state in their specialty and acting within the scope of that license.
  • Provider agrees to abide by the Rules and Regulations of Medicare that govern the provision and payment of services for BlueCross BlueShield of South Carolina Medicare Advantage Health Plan Members.
  • Provider agrees to submit claim for services to BlueCross BlueShield of South Carolina Medicare Advantage Health Plan and agree to collect from the Member only their required cost share. Claims should be submitted electronically to BlueCross BlueShield of South Carolina using payer (carrier code) C62. Paper claims may be mailed to PO Box 100133, Columbia, SC 29202-9545.
  • Provider agrees to accept BlueCross BlueShield of South Carolina Medicare Advantage Health Plan’s payment to include any Member cost share as payment in full for services rendered. BlueCross BlueShield of South Carolina Health Plan’s payment for its PFFS Plan will be the Original Medicare allowance for participating providers less the Member’s cost share in accordance with the BlueCross BlueShield of South Carolina Health Plan’s benefit plan. Payment will be made for all Medicare covered services as well as other covered services in the BlueCross BlueShield of South Carolina Health benefit plan.
  • Provider agrees that in no event, including but not limited to nonpayment by BlueCross BlueShield of South Carolina Health Plan, insolvency of BlueCross BlueShield of South Carolina Medicare Advantage Health Plan or breach of these Terms and Conditions, shall the Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against an Enrollee of persons (other than BlueCross BlueShield of South Carolina Medicare Advantage Health Plan) acting on behalf of the Enrollee for services provided pursuant of these Terms and Conditions. This provision does not prohibit a Provider from collecting charges for non-covered services agreed to in advance in writing or cost sharing amounts in the BlueCross BlueShield of South Carolina Medicare Advantage Health Benefit plan.
  • Provider agrees to abide by the BlueCross BlueShield of South Carolina Health Appeals and Grievances procedures, which are available through www.SouthCarolinaBlues.com or by calling 800-605-3256.
  • Provider agrees to Issue the Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC). These notices can be accessed via the CMS Web site at www.cms.hhs.gov/mmcag.
  • Providers who do not agree to our T&C may not treat BlueCross BlueShield of South Carolina Medicare Advantage Health Members and may not bill the Member or BlueCross BlueShield of South Carolina for services rendered.
  • Federal health care providers are not eligible for reimbursement by BlueCross BlueShield of South Carolina Medicare Advantage Health Plan for services rendered to its members except in an emergency.
  • If you are a Provider who is not eligible to receive payment under Original Medicare, you cannot participate in this plan.

OMB Approval No. 0938-0829 Form No. CMS-10003-NDP (June 2001)