BCBSRI is not a PPO network sharing plan and as such we are not allowed to price based on our participating provider contract. When a provider in our service area sees a Medicare member from another plan, they are considered non-network. However, they are treated as a Medicare participating provider. CMS requires Medicare Advantage (MA) plans to pay non-network providers at least the rates that they would be paid by FFS Medicare, as this is how we process all MA out-of-area claims.

CMS publishes a document which indicates how an MA plan must pay out-of-network providers. BCBSRI pays each service based on how the provider is paid by FFS Medicare. As a provider you are required to bill BCBSRI if you were billing Medicare, and you must accept this payment as payment in full and must not balance bill the member. For more information pertaining to the MA Payment Guide for Out-of-Network Payments, please click here.

For both commercial and Medicare Advantage PPO plans (where the member’s card has a suitcase with “PPO” indicated), the member’s network is broad and the contracted rates with BCBSRI are used to pay for the claim. HMO-based/managed care plans, including Medicare Advantage HMO, usually have a specific service area and if a member gets care outside of their main service area, the home network that manages the account determines the coverage and payment rates.