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

Medicare Advantage offers Medicare beneficiaries several types of product options, including:

  • Point-of-service (POS)
  • Private-fee-for-service (PFFS)
  • Medical Savings Account (MSA)
  • 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 Medicare Advantage 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 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 from you.

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

If you are a Regence MedAdvantage PPO provider and see Medicare Advantage 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 PPO contracted rate

If you are not a Regence MedAdvantage PPO provider and see Medicare Advantage PPO members from other Blue Plans, you will receive the Medicare allowed amount (not Regence MedAdvantage PPO 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.

Submit claims for ONLY statutorily excluded services to Regence. Providers should submit only those services that are statutorily excluded by Medicare (e.g., home infusion therapy and hearing aids) to their local Blue Plan, Regence. (Note: For Medicare Crossover claims that do not include statutorily excluded services, you must wait 30 days to submit claims to Regence.)

Claims for the service that is excluded or not covered by Medicare should be submitted with Modifier -GY on each line:

  • Modifier -GY should be used to indicate that the item or service is statutorily excluded. This will allow Regence to apply the contracted rate with the provider to accurately process the claim according to the member's benefits.
  • By submitting statutorily excluded services with a Modifier -GY directly to Regence, you will receive payment for these services in a more timely manner.

This modifier should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe services, a "not otherwise classified code" (NOC) must be used with Modifier -GY.

Modifier -GY is located in the line level procedure code modifier field(s) and the modifier can be:

  • Present position 1, 2, 3 or 4.
  • On the 837P Modifier -GY is found at level 2400, Service Line Loop in SV101-3, SV101-4, SV101-5 or SV101-6.
  • On the 837I Modifier -GY is found at level 2400, Service Line Loop in SV202-3, SV202-4, SV202-5 or SV202-6.

Claims for statutorily excluded services submitted to Medicare will be returned. When a provider submits a claim to Medicare for services that are statutorily excluded and not covered by Medicare (however, the member has benefits for those services), the claim will crossover to the member's Blue Plan. The member's Blue Plan will deny the statutorily excluded services and indicate that the provider needs to submit those services directly to their local Blue Plan, Regence.

Instructions will be included in an electronic remittance advice (ERA) or letter from the Blue Plan.

ERAs (835): The following HIPAA claim adjustment reason codes and remark codes will be included on the 835 responses:

  • Claim Adjustment Reason Code (CARC) 109: "Claim not covered by this payor/contractor."
  • Remittance Advice Remark Code (RARC) N837: "Alert: submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information."
  • Group Code: OA

Letters: When receiving a letter, you will receive instructions similar to the message below:

This service is excluded or not covered under Medicare. However, the service may be eligible for benefits under other coverage. Please submit this service to your local Plan.