Access our secured site
LoginLogin
Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

Search our online provider directory when you need a doctor, hospital, or other health care provider.

Smart Value

PW_AD052035
 
Plan & Administrative Changes/Updates for Providers:
We will continue to provide PFFS run- out services for 2011 dates of service through 12/31/12. For original claims, providers have one year from the date of service to submit a claim for processing. Provider submitted adjustment (determination) requests, for PFFS providers, will be accepted up to one year from the original claim processing date or the date of the most recent claim determination. 
 
Click here for important Medicare Advantage updates!  
 
SmartValue Private Fee For Service Plan
SmartValue from Blue Cross and Blue Shield of Georgia (BCBSGa) is an innovative new plan available to Medicare beneficiaries in select areas that are easy to participate in:  
The SmartValue Plan works much the same way original Medicare does. For a summary of what the plan covers, see the 2010 Summary of Benefits or the 2011 Summary of Benefits
There are no referrals for you to process.
SmartValue members are free to go to any hospital or to see any health care provider they choose, as long as the provider is eligible to receive payment by Medicare and agrees to the SmartValue Plan's Terms and Conditions.
Members of the SmartValue Plus plan have a Medicare Part D prescription drug benefit as part of the plan. See Our Drug List.
 
To participate in this plan:  
You agree to the Terms and Conditions of the Plan as defined in our Provider Disclosure/Terms & Conditions for 2010* and Provider Disclosure/Terms & Conditions for 2011*. (You do this automatically when you extend Medicare-covered services to a SmartValue member.)
You simply send claims to SmartValue instead of Medicare.
You'll be reimbursed according to the current Medicare Allowable Fee Schedule for your area**. For more information on how we calculate reimbursement rates, please see the SmartValue Payment Methodology Grid.
 
FAST TRACK APPEALS 
Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Medicare Advantage (MA) Programs. Financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers or the MA health plan. Download the forms and instructions below.  
Explanation of: What Beneficiary Notice Form to Use
Beneficiary Notice Forms (click health plan form below to retrieve)
NOMNC Notice of Medicare Non-Coverage.
DENC Detailed Explanation of Non-Coverage.
NDMC Notice of Denial of Medical Coverage.
NDP Notice of Denial of Payment.
Beneficiary Notice Forms (on www.cms.hhs.gov/bni)
IM Important Message from Medicare
Detailed Notice of Discharge
 
Additional Resources
Medicare Coverage Homepage
EDI - 270/271 Eligibility Instructions
Institutional billing codes are available from the NUBC via the NUBC's Official UB-04 Data Specifications Manual. To be redirected to NUBC click here
ID Card
Medicare Advantage Private Fee-For-Service Claims Edits
Medicare Part D Coverage Determination Request Form (for use by provider)
Optional PFFS Pre-Notification Fax Form
Affordable Care Act (ACA)
Formerly known as Patient Protection and Affordable Care Act
PFFS Contact Reference Guide
Pre-Determination Tip Sheet for Providers
PFFS Payment Dispute Request Form
PFFS Payment Reconsideration/Adjustment Form
Plans Terms and Conditions Look Up Tool
Preventive Health Guidelines
Provider Independent Review Request
Quick Reference Guide to the CMS 1500
Revision of Definition of Compendium in the Medicare Benefit Policy Manual; Chapter 15; Section 50.4.5
Request Form for Organizational Determinations
SmartValue Provider Manual
Summary of Independent Review Process
Waiver of Liability Form
 
We want to be sure you have no reservations about providing services to our members. We invite you to learn more about SmartValue by reading our Frequently Asked Questions.  
 
You can call 1-866-364-2374 for more information about the Private Fee-For-Service Plan.  
 
© 2014 BlueCross BlueShield of Georgia
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.