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Participation Requirements

Provider Administrative Policy

Provider Information
Policy Date
November 2007
Revised/May 2008


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Participation Requirements

The Centers for Medicare and Medicaid Services (CMS) requires the following:

  • Providers agree to cooperate with an independent quality review and improvement organization’s activities pertaining to provision of services for Medicare members in Medicare Advantage.
  • Providers comply with Medicare Advantage’s medical policies, quality improvement projects (QIP) and quality management program. Medicare Advantage must develop these policies, programs and standards in consultation with contracting providers.
  • Providers agree to allow appropriate personnel of Medicare Advantage, Health and Human Services, Comptroller General and other designees of these agencies to inspect, evaluate and audit any pertinent books, documents and records relating to services provided to Medicare Advantage members.
  • Medicare Advantage and its providers agree to provide all covered benefits in a manner consistent with professionally recognized standards of health care and services, and must provide them in a culturally competent manner.
  • Medicare Advantage must disclose to CMS the quality and performance indicators for the beneficiaries under the plan regarding disenrollment rates for members enrolled in Medicare Advantage for the previous two years.
  • Medicare Advantage must disclose to CMS the quality and performance indicators regarding member satisfaction with the plan and their providers.
  • Medicare Advantage must disclose to CMS the quality and performance indicators regarding health outcomes of members.

Summary of Benefits

Please refer to the current year product specific summary of benefits and evidence of coverage for benefit details. For additional information see MA PAP102.

Policy History

Date Action Reason
May 2008 Revised Format issues

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