Medicare Part C (Medicare Advantage)
Medicare benefits delivered through private health plans contracted with CMS, often with additional benefits and a managed-care structure.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Payer
- Primary sources
- 1
- Workspace handoff
- ask d3 →
Where this comes up
Front-office and billing both hit this term — eligibility before the visit, prior auth before the procedure, contract terms during fee-schedule negotiation, and credentialing whenever a new provider joins or a payer roster lapses. Misses here become denials downstream.
Full definition
What it is in practice
CMS Medicare Advantage pays MA plans a capitated risk-adjusted rate per enrollee. MA plans use HCC scoring and quality star ratings.
How it shows up in your practice
MA contracts often require pre-authorization for services Original Medicare does not. Track network status, fee schedules, and quality measures separately for each MA contract.
Sources
- CMS — Medicare Advantage (Part C)https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats
Look up MA contract rules in Ask D3
Open ask d3 →Related terms
- PayerMedicare Part AThe hospital insurance part of Medicare, covering inpatient hospital, skilled nursing facility, hospice, and limited home health.
- PayerMedicare Part BThe medical insurance part of Medicare, covering physician services, outpatient care, durable medical equipment, and preventive services.
- DocumentationHCC (Hierarchical Condition Category)The CMS risk-adjustment model that groups ICD-10 codes into categories used to predict the cost of care for Medicare Advantage enrollees.
- PayerPrior AuthorizationPayer requirement that the practice obtain approval before delivering certain services, procedures, or drugs.
- Compliance ProgramValue-Based CareReimbursement models that pay providers based on quality and outcomes rather than fee-for-service volume.
- PayerMedicare Stars RatingFive-star quality rating system CMS publishes annually for Medicare Advantage and Part D plans.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryMedicare Stars RatingFive-star quality rating system CMS publishes annually for Medicare Advantage and Part D plans.
- GlossaryPrior AuthorizationPayer requirement that the practice obtain approval before delivering certain services, procedures, or drugs.
- GlossaryHCC (Hierarchical Condition Category)The CMS risk-adjustment model that groups ICD-10 codes into categories used to predict the cost of care for Medicare Advantage enrollees.
- GlossaryMedicare Part AThe hospital insurance part of Medicare, covering inpatient hospital, skilled nursing facility, hospice, and limited home health.
- GlossaryMedicare Part BThe medical insurance part of Medicare, covering physician services, outpatient care, durable medical equipment, and preventive services.
- GlossaryValue-Based CareReimbursement models that pay providers based on quality and outcomes rather than fee-for-service volume.
- ComplianceOIG LEIE Monthly Exclusion Screening: Process + Audit-Ready LogsMonthly OIG LEIE and SAM.gov exclusion screening for every workforce member and vendor: the workflow, the log fields auditors require, and the escalation path.
- RegulationMLN: 'Incident To' Services in Medicare Part BReference to Medicare's incident-to billing rules permitting auxiliary personnel to furnish services billed under the physician's NPI, with strict supervision and treatment-plan requirements.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.