Terms and Conditions |Proxy Grid

The Terms and Conditions of participation establish the rules that you as a provider, who is Medicare-approved and licensed to provide services to Medicare recipients, must follow if you choose to furnish services to an enrollee of a private fee-for-service (PFFS) plan. At a minimum the terms and conditions will specify:

• The amount the PFFS organization will pay for all plan-covered services;
• Provider billing procedures;
• The amount the provider is permitted to collect from the enrollee; and whether the provider must obtain advance authorization from the PFFS organization before furnishing a particular service.

If you furnish a service to a PFFS enrollee that is not covered by the plan, the PFFS organization is not required to pay for the service. A private fee-for-service organization is required to make its terms and conditions of participation reasonably available to providers in the U.S. from whom its enrollees seek health care services. This generally means that the organization offering the PFFS plan will post its terms and conditions on a Web site and also make them available upon written or phoned request.

Terms and Conditions (PDF)

Related Links
Summary of Benefits (PDF)
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