Reimbursement Methodology

The BlueMedicare PFFS Payment Methodology Grid (PDF) describes how Blue Cross and Blue Shield of Florida (BCBSF) will calculate payment claims for covered items and services rendered to BlueMedicare PFFS plan members.

This grid indicates the methodology used to price services allowed under Medicare coverage guidelines for Medicare Advantage plans. The adjudication process will include any Correct Coding Initiative (CCI) edit rules. Actual claim payment is subject to eligible member benefits in effect on the date services are rendered, and may be reduced by applicable member cost-sharing (copayment) amounts.

Any questions related to claim reimbursement methodology should be directed to our Provider Contact Center at 1-800-727-2227.

BlueMedicare PFFS has a Medicare Advantage contract approved by the Centers for Medicare & Medicaid Services. Contracts are renewed annually and availability of coverage beyond the end of the current contract year is not guaranteed. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. A doctor or hospital must agree to accept the plan's terms and conditions prior to providing health care services to a member, with the exception of emergencies. If a doctor or hospital does not agree to accept our payment terms and conditions, they may not provide health care services to the member, except in emergencies.