Medicare Advantage Contract Submission for Wraparound Payment

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

• 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: Detailed Claim List Form (XLSX).