CMS Pub. 100-16, ch. 6, § 10

Chapter 6 of this manual focuses on the requirements for relationships between Medicare

Advantage organizations (MA organizations) and the physicians and other health care

professionals and providers with whom they contract to provide services to Medicare

beneficiaries enrolled in an MA plan. This chapter also contains some requirements that

apply to non-contract providers that furnish services to beneficiaries enrolled in an MA

organization. The policies in this chapter are derived from Subpart E of Part 422 of the

Code of Federal Regulations, and include additional instructions intended to provide

further guidance on implementation of regulatory requirements. The statutory basis for

the regulations at 42 CFR, Part 422 is set forth in the preambles to three final rules

published in the “Federal Register”: a June 26, 1998, Interim Final Rule requesting

public comment (63 FR 35068), and two final rules responding to public comments on

the interim final rule, published on February 17, 1999 (64 FR 7980) and June 29, 2000

(65 FR 40316).

Note that other policies relevant to providers are addressed in other chapters:

See Chapter 11, “Contracts with Medicare Advantage Organizations,” for information

on:

• MA organization oversight responsibility for contractors, subcontractors, and

related entities (see 42 CFR 422.502(i)): It is the responsibility of the MA

organization to ensure through written arrangements that all applicable laws,

regulations, and other instructions are followed.

• Prompt payment by MA organizations to contracting and non-contracting

providers (see 42 CFR 422.502(c), 422.520).

• Beneficiary financial protections from inappropriate liability in the event of

provider terminations (see 42 CFR 422.502(g)).

See Chapter 4, “Benefits and Beneficiary Protection,” for information on:

• When the MA organization must pay non-contract providers (see

42 CFR 422.100(b)). Section 100 of this chapter also contains information on

what non-contract providers must accept as payment in full (see

42 CFR 422.214).

• Notice to beneficiaries in the event of provider terminations (see

42 CFR 422.111(e)).

See Chapter 10, “ Organization Compliance With State Law and Preemption By Federal

Law,” for information on:

• Federal preemption of state law (see 42 CFR 422.402). Pursuant to

§1856(b)(3)(ii) of the Social Security Act, state laws or regulations relating to

inclusion or treatment of providers are specifically superseded by Federal law.

Note that 42 CFR 422.216, Special rules for MA private fee-for-service plans, is not

included in this chapter.