Payment Rules for Deemed Providers

70.3.3 - Payment Rules for Deemed Providers (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) • 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.