Medicare AdvantageAdministrativeMedium impact
MAPAP249 - Medicare Opt-Out, Excluded, and Precluded Providers - Added information regarding payment direction.
Blue Cross of Idaho·ID·Reimbursement
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
Policy MAPAP249 was updated in January 2026 to add information regarding payment direction for Medicare opt-out, excluded, and precluded providers. The policy clarifies how claims are processed and paid when providers have opted out of Medicare or are excluded/precluded from Medicare participation.
Action Required
Immediately: Billing team must review current opt-out provider processing workflows to ensure compliance with payment direction rules. For Medicare opt-out providers with secondary Blue Cross of Idaho coverage, process claims as primary with allowed amount as lesser of 20% of billed charge or 20% Blue Cross maximum allowable. For Medicare supplement claims with opt-out providers, pay member directly since provider doesn't accept Medicare assignment. Update billing system to flag excluded and precluded providers who are not eligible for payment after 60-day expiration periods.