US · guidance
CMS Pub. 100-16, ch. mc86c16a, § 70.2.2
Payment Rules for Deemed Providers
• The plan must pay all deemed providers at least the Original Medicare rates or
higher. Specifically, the total payment rates for these providers (plan and member
portions) must be at least the amounts they would have received as participating
or non-participating physicians, as applicable, under Original Medicare for
Medicare-covered services, including balance billing up to the limiting charge for
non-participating physicians. Refer to section 80.1 of this chapter.
• The plan must establish the payment rates for deemed providers in its terms and
conditions of payment and cannot vary the rates for deemed providers within a
particular category of Part A or Part B service.
History
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
1d7cb6e795fd84ddbbe54619468e5d22a7212b5e3ee8834053f11aedf5de6cb9
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