With the introduction of Medicare Advantage (formerly known as Medicare+Choice) plans in 1999, CMS implemented a significant number of regulations and requirements for health plans as well as their contracted network of providers. As a participating physician, other health care professional or facility with a Medicare Advantage plan, Regence MedAdvantage, you are required to comply with these regulations and requirements. Your provider agreement outlines these regulations and requirements. Some of the regulations to be aware of are listed below:

• Medicare Advantage plans allow members to be out of the service area for up to six months before being disenrolled.
  
  
• Medicare requires all members of Medicare Advantage to have a health risk assessment within 90 days of enrollment. Regence will send all newly enrolled members a Health Risk Assessment (HRA). Regence will assist physicians with case management for their patients who have complex or serious medical conditions.
  
  
• Physicians, other health care professionals and facilities may not deny, limit or apply conditions to the coverage or furnishing of covered services to members enrolled in a Medicare Advantage plan on the basis of any condition related to the member’s current health status.
  
  
• Physicians and other health care professionals may not impose any cost-sharing to Medicare Advantage plan members for influenza or pneumococcal vaccine.
  
  
• Neither Regence, nor the physician or other health care professional shall make any specific payment, directly or indirectly, to another physician or physician group as an inducement to reduce or limit medically necessary services furnished to a Medicare Advantage plan member.
  
  
• Providers agree to provide all encounter data necessary to characterize the context and purpose of each encounter with a Medicare Advantage plan member and a physician, other health care professional or facility. Physicians, other health care professionals and facilities agree that all encounter data will be used by Regence in validating its rates with CMS and that all encounter data and other information submitted to Regence and ultimately CMS is accurate, complete, and truthful and is based on the physician’s, other health care professional’s or facility’s best knowledge, information and belief. Physicians, other health care professionals and facilities acknowledge that misrepresentations about the accuracy of encounter data may result in Federal civil action and/or criminal prosecution.
  
  
• Providers agree not to bill Regence MedAdvantage plan members for covered services (except for copayments or coinsurance) if payment has been denied because the provider has failed to comply with the terms of the Agreement between the provider and Regence. Providers must notify the Regence MedAdvantage member of their financial obligation for non-covered services.
  
  
• Physicians, other health care professionals and facilities, and entities delegated by them to perform administrative services, are covered entities under Federal and state privacy laws. To the extent required by law, providers, Regence and our contracted business associates will keep all medical records containing patient-identifiable information confidential and will not disclose any patient-identifiable information to any third party without the prior written consent of the member.
  
  
• Providers shall ensure services are documented in the member’s primary care medical record. It is important for specialty physicians and other providers to advise the referring physician when follow-up care is necessary.
  
  
• Providers are responsible for the education and training of all individuals working within their medical practice to ensure that procedures outlined in the Administrative Manual are followed correctly. You may contact Provider Services to request staff training that may include, but is not limited to, billing procedures and administrative policies.
  
  
• Physicians, other health care professionals and facilities will make individual medical records available to patients or their legally designated representative upon request.
  
  
• At all reasonable times, physicians, other health care professionals and facilities will provide Regence, CMS, the Comptroller General of the United States, and their duly authorized representatives the right of access to its facilities and to its financial and medical records which are directly pertinent to Medicare Advantage plan members in order to monitor and evaluate cost, performance, compliance measures reporting, quality improvement activities, appropriateness, and timeliness of services provided.
  
  
• In the event Regence terminates its Medicare Advantage contract with CMS, physicians, other health care professionals and facilities agree to continue to furnish health care services for Medicare Advantage plan members for:
  1. The duration of the period for which premiums have been paid and,
  2. If the member is hospitalized on the date of termination or in the event of insolvency, through date of discharge from the hospital.
  
  
• The payments that physicians, other health care professionals and facilities receive from Regence MedAdvantage are, in whole or in part, Federal funds. We comply with all laws and regulations applicable to entities receiving Federal funds.
  

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