Medicare Advantage Contract Submission for Wraparound Payment

Published 02/09/2023

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: Detailed Claim List Form (XLSX).

The information can be sent via email to or by mail to the address below:

Provider Reimbursement
2300 Springdale Drive, Building One
Camden, SC 29020

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