Inter-Plan Medicare Advantage Program Sample Clauses
The Inter-Plan Medicare Advantage Program clause establishes the framework for cooperation and coordination between different health plans participating in Medicare Advantage. It typically outlines how claims, payments, and member information are shared and processed when a Medicare Advantage member receives services outside their home plan’s network, such as when traveling or temporarily residing in another area. This clause ensures that members continue to receive covered benefits seamlessly and that providers are reimbursed appropriately, thereby facilitating continuity of care and administrative efficiency across multiple plans.
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Inter-Plan Medicare Advantage Program. Blue Cross and Blue Shield also participates in the Inter-Plan Medicare Advantage Program, the Inter-Plan Program for Members enrolled in a Medicare Advantage plan. In the event you elect to offer a Medicare Advantage plan to your Medicare-eligible Members, when Medicare Advantage Members access health care services outside of Massachusetts, the claim for those services will be processed through the Inter-Plan Medicare Advantage Program and presented to Blue Cross and Blue Shield for payment in accordance with the rules of the Inter-Plan Medicare Advantage Program policies then in effect. The Inter-Plan Medicare Advantage Program available to Members under this Agreement is described generally as follows. The cost of the covered health care service on which a Member’s cost share liability (such as coinsurance) is based will be either: The Medicare allowable charge for covered services, or The amount either Blue Cross and Blue Shield negotiates with the provider or the Host Plan negotiates with its provider on behalf of Blue Cross and Blue Shield members, if applicable. The amount negotiated may be either higher than, lower than, or equal to the Medicare allowable charge.
Inter-Plan Medicare Advantage Program. Determination of Compliance:
1. Guidelines Subject to Immediate Termination
1.1 None
2. Guidelines Subject to Mediation/Arbitration
2.1 BlueCard Program and ITS — A controlled affiliate shall fully participate in ITS and the BlueCard Program through compliance with all BlueCard Program Policies and Provisions and all applicable Inter-Plan Programs Policies and Provisions, unless an exemption has been granted by the Inter-Plan Programs Committee (IPPC) in accordance with those Policies and Provisions.
2.1.a Compliance determined by periodic reviews or audits and by reviews initiated by evidence of problems.
2.1. b Mediation/Arbitration shall be commenced only upon a finding by IPPC that such action is warranted and a referral of the matter from IPPC to the PPFSC and the BCBSA Board of Directors for their action.
Inter-Plan Medicare Advantage Program. A Plan shall fully participate in the Inter-Plan Medicare Advantage Program through compliance with all Inter-Plan Medicare Advantage Program Policies and Provisions.
Inter-Plan Medicare Advantage Program. A Controlled Affiliate shall fully participate in the Inter-Plan Medicare Advantage Program through compliance with all Inter-Plan Medicare Advantage Program Policies and Provisions.
Inter-Plan Medicare Advantage Program. Determination of Compliance: