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PFFS Plan Terms and Conditions of Payment

PFFS plans create terms and conditions of payment, which establish the payment rates for plan-covered items and services that apply to deemed providers (see Chapter 16a of the Medicare Managed Care Manual for definitions of the types of providers who furnish services to PFFS members), and the rules that deemed providers must follow in order to be paid by the PFFS plan for furnishing services to its members. PFFS plans must ensure that providers furnishing services to plan members are paid accurately and timely according to the terms and conditions of payment. These terms and conditions must be readily available in order for deemed providers to make an informed decision on whether to treat a PFFS plan member.

Click below on “Model Private-Fee-For-Service Terms and Conditions of Payment” for guidance about the PFFS Terms and Conditions, as well as the Model Terms and Conditions.