Who Processes The Claim
Original Medicare claims go to the MAC for the jurisdiction. Medicare Advantage claims go to the private plan the patient is enrolled in. Sending an MA patient's claim to the MAC results in a denial, so eligibility should be verified at every visit, since patients can change plans each year.
Coverage Rules
Since 2024, Medicare Advantage plans must follow Original Medicare coverage criteria, including national and local coverage determinations, for basic benefits. Plans may use their own criteria only when Medicare coverage criteria are not fully established. Plans can still require prior authorization and use utilization management.
Networks And Payment
Contracted providers are paid under their contract with the plan, which may differ from the Medicare fee schedule. Non-contracted providers who treat an MA patient are generally paid what Original Medicare would pay. Network status affects the patient's cost sharing, and some plans do not cover out-of-network care except in emergencies.
Prior Authorization And Appeals
Medicare Advantage plans use prior authorization much more widely than Original Medicare. From 2026, plans must meet federal decision timeframes of 72 hours for expedited and seven calendar days for standard requests. Denied claims are appealed through the plan's process, not the MAC's, with different deadlines.
Exceptions Billed To Original Medicare
Some services for MA enrollees are still billed to Original Medicare, such as hospice care for patients who elected hospice and certain clinical trial costs. Check the CMS guidance for the specific service.
Frequently Asked Questions
- Do MA plans have the same timely filing limit as Medicare?
- Not necessarily. Contracted providers follow the filing limit in their contract, which is often shorter than one year.
Billing Support From PPBS
Physicians Professional Billing Services, Inc. has billed wound care, surgical and procedural specialties since 1998, across every Medicare Part B MAC jurisdiction.
Primary Sources
This page is general information about billing and coverage rules and is not legal, coding or reimbursement advice for a specific claim. Coverage policies change; confirm current requirements with CMS and the applicable Medicare Administrative Contractor.