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Medicare Advantage claims for out-of-network payments
Act
by Jul 1, 2026
Effective date
Jul 1, 2026
Identified
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.
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What to do
by Jul 1, 2026 · 4 steps
01Billing team must ensure all Medicare Advantage out-of-network claims are processed using FFS Medicare payment rates, not contracted rates.
02Update billing software to automatically apply FFS Medicare fee schedules for MA out-of-network claims from BCBSRI.
03Train billing staff to verify that no balance billing occurs on these claims and that payment is accepted as payment in full.
04Communicate to providers in your service area that they must bill BCBSRI directly for Medicare members and accept FFS rates without balance billing members.
If missed: Failure to comply will result in claim denials and potential compliance violations.
Original notice
Medicare Advantage claims for out-of-network payments
bcbsri.com · Always check the source before changing claims.
Related changes
See all Blue Cross Blue Shield of Rhode Island changes →Medicare Advantage claims for out-of-network paymentsMediumEffective Jan 1, 2019 · Provider UpdateMedicare Advantage claims for out-of-network paymentsMediumEffective Feb 1, 2019 · Provider UpdateMedicare Advantage claims for out-of-network paymentsMediumEffective Apr 1, 2024 · Provider UpdateMedicare Advantage claims for out-of-network paymentsMediumEffective Jul 1, 2024 · Provider UpdateBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list