Medicare Advantage Contract Submission for Wraparound Payment

Published 12/21/2020

For each Medicare Advantage (MA) plan, please submit a documented estimate of the average visit payment for the MA enrollees.
Documentation should include a cover letter with the provider list, as well as a contact name, and should be signed by the contact.
Each MA contract should include the following:
  • Contract number;
  • Provider name and MA contract name;
  • Contract dates;
  • Effective dates; and
  • Signatures from the provider and the MA contract representative
The rate calculation should include the following:
  • Contract number
  • Procedure codes
  • Units
  • Rates
  • Payment amounts and
  • MA payment rate per visit
A detailed claims list that supports the information in the rate calculation should also be included.

The information can be sent via email to JMReimbursement@palmettogba.com or to the address below:

Provider Reimbursement
AG-330
2300 Springdale Drive, Building One
Camden, SC 29020