Medicare Advantage PFFS

HMSA does not offer a Medicare Advantage Private Fee For Service (PFFS) plan. The information below is for healthcare providers who render services to members who have Medicare Advantage PFFS coverage offered by out-of-area Blue Cross Blue Shield plans.

Product Definition

A PFFS plan offers as a minimum all of Medicare Part A and B services with additional services not covered by Original Medicare. The PFFS plan allows members to use any doctor, specialist or hospital that accepts the Blue Plans’ PFFS terms and conditions of plan payment, as long as the provider is lawfully authorized to provide services under Original Medicare. Read more.

If you experience any difficulties, please contact 1-800-676-BLUE (2583).

Eligibility

To verify member eligibility for a PFFS plan offered by a Blue Plan, contact 1-800-676-BLUE (2583) or submit an inquiry electronically to HMSA.

ID card

The information on the member ID card will let you know when the member is enrolled in a PFFS plan.

Providing Services for Blue Out-of-Area (from another Blue Plan) Member

PFFS plans offered by Blue Plans generally use the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Deemed Provider concept, rather than direct contracts, to arrange for services to members.

You are considered a Deemed Provider if each of the following three criteria are met:

• You are aware in advance of furnishing services, that the person you are treating is enrolled in a PFFS plan. Notice of enrollment can be obtained from various sources, including:
  • The member who presents his or her PFFS plan ID card or letter providing proof of insurance
  • 1-800-676-BLUE (2583)
  • CMS
• You access or have reasonable access to information about the PFFS Plan’s terms and conditions of payment. As a practical matter, this requirement is met where you have access to the terms and conditions of payment through the patient’s Blue Plan’s PFFS Web site, the Blue Plan’s provider services toll-free number, or various member and/or provider publications. (For your convenience, the contact information for obtaining details concerning the PFFS Plan’s terms and conditions of payment appear on the member’s ID card).
• You subsequently provide services to that member. If a provider is aware in advance of furnishing services that a person is enrolled in a PFFS Plan and the provider either possesses or has access to the Plan’s terms and conditions of payment (via the internet, telephone or otherwise), the provider is a Deemed Provider for the services rendered, except in limited instances (for example, where the member is treated in an emergency department of a hospital and the provider is required by law to see the patient).

Claims Filing Information for Blue Out-of-Area Members

• Hawaii providers furnishing care for out-of-area Blue PFFS members should file claims with HMSA using their HMSA provider number. Do not file claims to Medicare.
• Include the National Provider Identifier (NPI) on all claim submissions (paper or electronic) to HMSA.
• Providers should report the Member’s PFFS ID number with the prefix (not the Health Insurance Claim Number (HICN)).
• If a provider currently submits claims electronically to the local Blue Plan, the provider can submit PFFS claims using the following:
  • Source of Payment (Facility = x; and Professional = y)
  • Payer ID (Facility = a; Professional = b).
• The Provider’s name and credentials should be reported in Box 31 on paper CMS 1500 claims, or the equivalent field on the EDI 837.
• Hospice providers should file claims to Medicare.
• CMS requires Medicare Advantage organizations offering PFFS options to process and pay 95 percent of all clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, interest will be paid according to federal guidelines.
• All Medicare Secondary Payer rules apply. Providers should obtain information on primary payer coverage and bill accordingly.

Providing Care for Blue Out-of-Area Members When The Provider Does Not Accept The Terms And Conditions of Payment

General Rule: If a provider is aware that a member is a PFFS Plan enrollee but chooses not to accept the PFFS Plan’s terms and conditions of payment, the provider should not furnish services to the PFFS Plan member, except in urgent or emergency care situations.

Urgent/Emergency Care: When a provider that furnishes services to a PFFS member in an urgent or emergency care situation informs the PFFS Plan that it does not wish to be treated as a Deemed Provider, it will receive payment equal to what it would have received under Original Medicare. In this context, the provider may only collect the applicable co-payments or coinsurance under the PFFS plan from the member. See the members’ card for the location of terms and conditions of payment including balance billing restrictions or call HMSA’s BlueCard Program at 808-948-6280 on Oahu or 1-800-648-3190 from the Neighbor Islands.

Payment Information for Out-of-Area Members

• For reimbursement information (including cost sharing, co-payments, deductibles, balance billing restrictions) prior to rendering services for out-of-area Blue Plan PFFS members, review the Plan’s terms and conditions of payment. See the member’s ID card as how to access the Plan’s terms and conditions or call HMSA’s BlueCard Program at 808-948-6280 on Oahu or 1-800-648-3190 from the Neighbor Islands.
• For questions regarding claim payment adjudication (including cost sharing, co-payments, deductibles, balance billing restrictions) after services have been rendered, contact HMSA’s BlueCard Program at 808-948-6280 on Oahu or 1-800-648-3190 from the Neighbor Islands.

Claims Appeal

If a provider thinks that the payment amount the provider received for a service (including the member cost sharing collected) is less than it would have received under Original Medicare for the service, the provider can appeal the payment amount. Call HMSA’s BlueCard Program at 808-948-6280 on Oahu or 1-800-648-3190 from the Neighbor Islands for claims appeal information, or review the claims appeal process in the terms and conditions of payment. The location of the terms and conditions of payment can be found on the member’s ID card.

Utilization/disease/care Management Programs or Prior Authorization

Information on utilization, disease, care management programs or prior authorizations may be obtained by calling the number on the member’s ID card or by calling 1-800-676-BLUE (2583).

Revision History