Medicare Advantage (MA Delegated or Capitated) - Capitation and/or Delegation Supplement, 2018 Administrative Guide

Claims Processing

MA contracted care provider claims must be processed in accordance with the agreed upon contract rates and within applicable federal regulatory requirements. Claims are to be adjudicated within 60 calendar days of receipt.

MA non-contracted care provider claims should be reimbursed in accordance with the current established locality-specific Medicare Physician Fee Schedule, DRG, APC, and other applicable pricing published in the Federal Register. Non-contracted, clean claims must be adjudicated within 30 calendar days of receipt. Non-clean claims are to be adjudicated within 60 calendar days of receipt.

Interest Payment Requirements

CMS requires the payment of interest for non-contracted care provider clean claims not paid within 30 calendar days from the first date stamp. Interest is paid at the current rate for the period beginning on the day after the required payment date and ending on the date the check is mailed.

CMS updates the interest rate twice annually, in January and July. You can find this information in the Federal Register or on the official CMS website.