Medicare Advantage billing and authorizations
Billing for Medicare Advantage plans run by private insurers, with plan-specific networks, prior authorization, referrals and payment rules.
Working with Medicare Advantage
Medicare Advantage (Part C) plans are offered by private insurers such as UnitedHealthcare, Humana, Aetna, Wellcare, and Blue Cross plans.
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Claims go to the plan, not to your MAC, and each plan sets its own authorization and referral rules within Medicare coverage requirements.
Plan types we bill:
- HMO and PPO plans
- Special needs plans (SNPs), including dual-eligible plans
- Private fee-for-service plans
Credentialing and enrollment
Network participation is separate for each plan and often each product. Out-of-network providers who are enrolled in Medicare can still be paid by many PPO and PFFS plans at Original Medicare rates.
Prepare
Licenses, NPI, CAQH and group details checked and updated.
Apply
Application submitted for each provider and location.
Follow up
Status checked every 1 to 2 weeks until approval.
Confirm
Effective date and participation confirmed before billing.
Claims, eligibility and portals
Under the CMS Interoperability and Prior Authorization Final Rule, Medicare Advantage plans must decide expedited prior authorization requests within 72 hours and standard requests within 7 calendar days, starting in 2026. We track every authorization and its approved services.
Denials we prevent with Medicare Advantage
- Claim sent to the MAC instead of the plan
- Missing plan prior authorization or referral
- Provider out of network for an HMO plan
- Inpatient status denials
- Coding differences from Original Medicare policies
Questions about Medicare Advantage
How do we know if a patient has Medicare Advantage?
Eligibility checks show Medicare Advantage enrollment. We check before each visit so the claim goes to the right payer.
Other payers and related services
Trademarks belong to their owners. MedAi Billing Solutions is an independent billing company, not affiliated with any payer or government agency.
Get help with Medicare Advantage claims
Send a few details and we will set up a short call to review your claims, denials and A/R. No cost and no commitment.
We sign a Business Associate Agreement before we handle any patient data.