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Under the BlueCross BlueShield of SC Health Private Fee-For-Service Plan, enrollees can see any willing Medicare-eligible provider. In general, the BlueCross BlueShield of SC 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 SC Medicare Advantage Health Plan Members,
- Provider agrees to submit claim for services to BlueCross BlueShield of SC 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 SC using payer (carrier code) 401. Paper claims may be mailed to PO Box 100133, Columbia, SC 29202-9545.
- Provider agrees to accept BlueCross BlueShield of SC Medicare Advantage Health Plan’s payment to include any Member cost share as payment in full for services rendered. BCBSSC 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 BCBSSC Health Plan’s benefit plan. Payment will be made for all Medicare covered services as well as other covered services in the BCBSSC Health benefit plan.
- Provider agrees that in no event, including but not limited to nonpayment by BCBSSC Health, insolvency of BCBSSC 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 BCBSSC 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 BCBSSC Medicare Advantage Health Benefit plan.
- Provider agrees to abide by the BCBSSC 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.gov/healthplans/appeals <http://www.cms.gov/healthplans/appeals>. For additional information on these requirements, visit the following Web page: <http://cms.hhs.gov/healthplans/appeals/providerarticle1124.pdf>.
- Providers who do not agree to our T&C may not treat BCBSSC Medicare Advantage Health Members and may not bill the Member or BCBSSC for services rendered.
- Federal health care providers are not eligible for reimbursement by BCBSSC 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.
A complete copy of the BCBSSC Medicare Advantage Health Plan’s Terms and Conditions is available upon request from our Member Service Center at 800-605-3256.
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