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Blue Advantage® Compliance with CMS Regulations
Participating providers with Blue Advantage must adhere to the terms and conditions of the Centers for Medicare & Medicaid Services (CMS) contract.
All Blue Advantage participating providers are required to accept the same terms and conditions where
appropriate. Compliance with the following CMS regulations is required:
- Healthcare providers are prohibited from holding a member liable for amounts that are the obligation of Blue Advantage.
- Providers must safeguard the privacy of any information that identifies a particular member and must maintain records in an accurate and timely manner.
- Providers must submit all data necessary to demonstrate the content and purpose of each encounter with
- Providers are prohibited from discriminating against any member based on health status.
- Providers must provide all covered services in a manner consistent with professionally recognized standards of healthcare.
- Providers are subject to all laws applicable to individuals/entities receiving federal funds and must comply with all other laws and regulations including Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, and the Americans with Disabilities Act.
- Providers must comply with Medicare appeal/expedited appeal procedures for beneficiaries.
- Blue Advantage will adhere to all CMS marketing provisions with regard to marketing and enrolling members into the program.
- Any payment and incentive arrangements among Blue Advantage and providers, first tier entities, and downstream entities shall be specified in all contracts.
- Providers must comply with all federal laws and regulations designed to prevent or ameliorate fraud, waste and abuse including, but not limited to, applicable provisions of the federal criminal law, the False Claims Act, the anti-kickback statute, and Health Insurance Portability and Accountability Act (HIPAA) administrative simplification rules at 45 CFR parts 160, 162 and 164.
- Providers must comply with the auditing and duplication of billing, payment and medical records requirements that pertain to members.
- Providers must comply with the limitations placed on imposing influenza or pneumococcal vaccine copayments.
- Providers must comply with the provisions regarding member advance directives in a member’s medical record.
- Providers must comply with the provisions on risk adjustment data submissions.
- Providers agree to comply with the provisions on maintaining medical policies and procedures.
- Providers must comply with the requirements for billing a member for services which are not covered under the Medicare Advantage Plan.
- Providers must comply with the obligation to repay Blue Cross for services paid incorrectly under the Blue Advantage (PPO) program.
- Blue Cross must comply with CMS’ requirements to provide written notice of suspension or termination to a provider as well as appeal rights.
Blue Advantage is a Medicare-approved PPO Plan.
Last Updated December 2013