Medicare AdvantageReimbursementHigh impact
Medicare Advantage claims for out-of-network payments
Blue Cross Blue Shield of Rhode Island·RI·Provider Update
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
BCBSRI clarifies that Medicare Advantage out-of-network providers must be paid at FFS Medicare rates and must accept this payment in full without balance billing members. Providers are required to bill BCBSRI for Medicare members and cannot use their participating provider contracts to negotiate higher rates for MA out-of-area claims.
Action Required
By July 1, 2026: Billing team must ensure all Medicare Advantage out-of-network claims are processed using FFS Medicare payment rates, not contracted rates. Update billing software to automatically apply FFS Medicare fee schedules for MA out-of-network claims from BCBSRI. Train billing staff to verify that no balance billing occurs on these claims and that payment is accepted as payment in full. Communicate to providers in your service area that they must bill BCBSRI directly for Medicare members and accept FFS rates without balance billing members. Failure to comply will result in claim denials and potential compliance violations.