Terms and Conditions of Payment for Medicare Advantage Programs

INTRODUCTION

Members enrolled in Medicare Advantage programs administered by Avesis may use any licensed provider, such as a dentist, optometrist, physician, health professional, hospital, or other Medicare provider in the United States that agrees to treat the member after having the opportunity to review these terms and conditions of payment. This is conditional on the provider being eligible to provide health care services under Medicare Part A and Part B (also known as 'Original Medicare') or eligible to be paid by Avesis for benefits that are not covered under Original Medicare.

The law provides that if you, as one of the provider types listed above, have an opportunity to review these terms and conditions of payment and you treat a member enrolled in a plan administered by Avesis, you will be "deemed" to have a contract with Avesis for these services. Section 2 explains how the deeming process works. The rest of this document contains the contract that the law allows us to deem to hold between you, the provider, and Avesis as the Medicare payor. Any provider in the United States that meets the deeming criteria in Section 2 becomes deemed to have a contract with Avesis for the services furnished to the member when the deeming conditions are met. No services covered by Avesis under these programs require prior authorization. For the convenience of the dental providers, the only covered services requiring a referral from Avesis are for dentures for members enrolled in Medicare programs that cover dentures. A member or provider may, however, request an advance organization determination before a service is provided in order to confirm that the service will be covered by the plan. Note that the terms prior authorization, prior notification, and advance organization determination have different meanings. Prior authorization, prior notification, and advanced determinations are discussed in Section 7.

WHEN A PROVIDER IS DEEMED TO ACCEPT AVESIS' TERMS AND CONDITIONS OF PAYMENT

A provider is deemed to have a contract with Avesis when all of the following three criteria are met:

  1. The provider is aware, in advance of furnishing health care services, that the patient is a member of a plan administered by Avesis. All of the members for whom we administer benefits receive an enrollment ID card that clearly identifies them as a plan member in plans Avesis administers. The provider may validate eligibility by calling our Customer Service Department at 1-800-327-4462.
  2. The provider has a copy of, or has reasonable access to, our terms and conditions of payment (this document). The terms and conditions are available on our website at www.avesis.com/termsandconditions. The terms and conditions may also be obtained by calling our Customer Service Department at 1-800-327-4462.
  3. The provider furnishes covered services to a member of a plan administered by Avesis.

If all of these conditions are met, the provider is deemed to have agreed to Avesis' terms and conditions of payment for that member specific to that visit. Note: You, the provider, can decide whether or not to accept Avesis' terms and conditions of payment each time you see a member of a plan administered by Avesis. A decision to treat one plan member does not obligate you to treat other members, nor does it obligate you to accept the same member for treatment at a subsequent visit.

For example: If a member of a plan administered by Avesis shows you an enrollment card identifying him/herself as a member and you provide services to that member, you will be considered a deemed provider. Therefore, it is your responsibility to obtain and review the terms and conditions of payment prior to providing services.

If you DO NOT wish to accept Avesis' terms and conditions of payment for a service you might render, then you should not furnish covered services to members of plans administered by Avesis. If you nonetheless do furnish covered services, you will be subject to these terms and conditions whether you wish to agree to them or not.

PROVIDER QUALIFICATIONS AND REQUIREMENTS

In order to be paid by Avesis for services provided to members, you must:

PAYMENT TO PROVIDERS

Payment Plan

Avesis reimburses deemed providers at the amount they would have received as participating Avesis providers minus any member required cost sharing, for all necessary services covered by the plan.

Avesis will process and pay clean claims within 30 calendar days of receipt or as otherwise required by the laws of the state in which the services are rendered. If a clean claim is not paid within the 30 calendar day or state required time frame, then we will pay interest on the claim according to Medicare guidelines. Section 5 has more information on prompt payment rules. Payment to providers for which Medicare does not have a publicly published rate will be based on the Avesis usual and customary amount.

Services covered under Avesis that are not covered under Original Medicare will be reimbursed using the Avesis in network fee schedule. You may request a copy of this fee schedule by contacting Avesis at 1-800-327-4462.

Deemed providers furnishings such services MUST accept the fee schedule amount, minus any applicable member cost sharing or copayment, as payment in full.

Member benefits and cost sharing

Payment of cost sharing amounts is the responsibility of the member. Providers should collect the applicable cost sharing from the member at the time that services are rendered, whenever possible. You can only collect from the member appropriate Avesis copayments or coinsurance amounts described in these terms and conditions. After collecting cost sharing from the member, the provider should bill Avesis for covered services. Section 5 provides instructions on how to submit claims to us.

To view a complete list of covered services and member cost sharing amounts under Avesis, go to www.avesis.com and select the appropriate plan type and state. You may also call us at 1-800-327-4462 to obtain more information about covered benefits, plan payment rates, and member cost sharing amounts under Avesis. Be sure to have the member's ID number when you call.

Prior notification rules

A referral is required as a condition of coverage for plan-covered denture services when furnished to members. To obtain a referral or more information about our referral requirements, call us at 1-800-327-4462.

Balance billing of members

A provider may collect only applicable plan cost sharing amounts from members and may not otherwise charge or bill members. Balance billing is prohibited by contracted providers and providers who are deemed to be contracted under the rules in Section 2 and who furnish plan-covered services to members enrolled in plans administered by Avesis.

Hold harmless requirements

In no event, including, but not limited to, nonpayment by Avesis, insolvency of Avesis, and/or breach of these terms and conditions, shall a deemed provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons acting on a member's behalf for plan-covered services provided under these terms and conditions. This provision shall not prohibit the collection of any applicable coinsurance, co-payments, or deductibles billed in accordance with the terms of the member's benefit plan.

If any payment amount if mistakenly or erroneously collected from a member, you must make a refund of that amount to the member.

FILLING A CLAIM FOR PAYMENT

You must submit a claim to Avesis for covered services within twelve (12) months from the date of service. Failure to be timely with claim submissions may result in nonpayment.

MAINTAINING MEDICAL RECORDS

Deemed providers shall maintain timely and accurate medical, financial, and administrative records related to services they render to members enrolled in plans administered by Avesis. Unless a longer time period is required by applicable statutes or regulations, the provider shall maintain such records for at least 10 years from the date of service.

PRIOR AUTHORIZATION, PRIOR NOTIFICATION AND GETTING AN ADVANCE ORGANIZATION DETERMINATION

There are no prior authorization requirements on services covered under programs administered by Avesis. In terms of prior notification, Avesis regards a referral as a form of prior notification, A referral is required for members seeking to obtain covered denture benefits under dental programs administered by Avesis. Providers may choose to obtain a written advance coverage determination for dental services (known as a predetermination) from us before furnishing services in order to confirm whether the services will be covered by us and what the reimbursement for the services will be. To obtain an advance organization determination, call us at 800-327-4462, or submit your request in writing to Avesis at PO Box 7777, Phoenix, AZ, 85011-7777. Avesis will make a decision and notify you and the member within fourteen (14) calendar days of receiving the request. If necessary, an extension of up to fourteen (14) days may be necessary in order to obtain all of the required information. In the absence of an advance coverage determination, Avesis can retroactively deny payment for a service furnished to a member if we determine that the service was not covered by our plan. However, providers have the right to dispute our decision by exercising his/her appeal rights.

PROVIDER PAYMENT DISPUTE RESOLUTION PROCESS

If you believe that the payment amount you received for a service is less that the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process.

To file a payment dispute with Avesis, send a written dispute to Avesis, PO Box 7777, Phoenix, AZ 85011, ATTN: Appeals Unit. Additionally, please provide appropriate documentation to support your payment dispute (e.g., a remittance advice form would be considered such documentation). Claims must be disputed within sixty (60) days from the date payment was initially received by the provider. Note that in cases where we readjudicate a claim, for instance, when we discover that we processed it incorrectly the first time, you have an additional sixty (60) days from the date you are notified of the readjudication in which to dispute the claim.

We will review your dispute and respond to you within sixty ( 60) days. If, based upon this review, the decision is to reverse our earlier payment decision, we will pay you the additional amount due including any applicable interest due. If, however, our decision is to uphold the initial determination, we will inform you of this in writing.

After Avesis' payment dispute resolution process has been completed, if you still believe that we have reached an incorrect decision regarding payment on your claim, you may file a grievance with Avesis.

A provider may appeal an organization determination on behalf of the member, as a representative, or sign a waiver of liability (promising to hold the member harmless regardless of the outcome) and appeal post-service organization determinations (e.g., claims) using the member appeal process. As noted above, there must be potential member liability in order for a provider to appeal utilizing the member appeal process.

If a provider appeals using the member appeal process, the provider agrees to abide by the statues, regulations, standards, and guidelines applicable to the Medicare Member appeals and grievances processes.

The Evidence of Coverage (EOC) provided by the member's health plan provides more detailed information about the member appeal and grievances processes.

If you have general questions about Avesis' Terms and Conditions of Payment, contact us at Avesis, 2300 Lake Park Drive, Suite 400, Smyrna, GA 30081 or by telephone at 800-327-4462, Monday through Friday, 7:00 a.m. to 8:00 pm. Eastern Time.

If you have questions about submitting claims or plan benefits, call us at 800-327-4462