Medicare_Carriers_Manual / 4260 / 4260

Why This Topic Matters

It helps readers identify when a group practice prepayment plan must submit claims to the carrier instead of relying on direct reimbursement, and it clarifies the types of situations addressed in this Medicare manual section.

Article Sections

1. Ed. Note: For further information see

   A brief editorial reference directing readers to related manual material on direct-dealing group practice prepayment plans.

2. 4260. Billing by Direct Dealing Group Practice Prepayment Plans

   An overview of billing and reimbursement guidance for direct-dealing group practice prepayment plans in selected situations. The section is organized into separate circumstances involving outpatient psychiatric services, services furnished outside the plan, and services to non-members.

3. A. Outpatient Psychiatric Services

   Guidance related to outpatient psychiatric services furnished by a group practice prepayment plan and the associated carrier reimbursement process.

4. B. Services Received Outside the Plan--Not 'Arranged For' by the Plan

   Guidance for services furnished outside the plan that were not arranged by the plan, including references to carrier reimbursement procedures.

5. C. Services to Non-Members

   Guidance addressing services furnished to non-members and the reimbursement setting described for those services.