Medicare Advantage Plans
Medicare Advantage Plans (MAPs) are plans offered by private companies that provide Part A, Part B, and Part D coverage in one plan. These plans are also referred to as Part C. MAPs cover all Medicare services. Most also offer extra coverage like vision, hearing, and dental coverage. A list of MAPs by zip code can be found at Medicare.gov.
Medicare Advantage Plan Prompt Pay
- For non-contracted providers, the MAP must follow the Centers for Medicare and Medicaid Services (CMS) prompt pay regulations. See the Medicare Managed Care Manual and the dispute resolution web page for information.
- The contract between CMS and the MA organization must provide that the MA organization will pay 95% of the "clean claims" within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an MA private fee-for-service plan or on claims for services that are not furnished under a written agreement between the organization and the provider;
- The MA organization must pay interest on clean claims that are not paid within 30 days (interest rates); and
- All other claims from non-contracted providers must be paid or denied within 60 calendar days from the date of the request for payment.
- For contracted providers, prompt pay terms are governed by the physician’s contract with the plan.
Where to File Complaints
- Medcare Advantage Plans and Part D:
Provide a detailed account of the issue with supporting documentation, if any, and your efforts to resolve the issue with the plan. Mail or email (securely) the complaint form along with your detailed account to the following:
Part C and D Complaint Form
Dallas Regional Office Contacts – Arthur Pagan, Assoc. Regional Administrator, 214-767-6418, RODALMAHPB@cms.hhs.gov. Emails not sent securely will not be processed.
Sequestration Guidelines for Medicare Advantage Plans
On May 1, 2013, CMS released additional information regarding the mandatory payment reductions in Medicare Advantage (MA) and stand-alone Part D plans. This additional information states, that Medicare Advantage Organizations (MAOs) payments to contracted physicians are governed by the agreement between the MAP and the physician. Additionally, CMS states that MAPs must follow prompt pay provisions established in their contracts with providers and to pay the providers under the terms of the contract. More information can be found in this CMS notice.