For Providers / Part C Non-Contracted Provider Claim Appeals
Part C Non-Contracted Provider Claim Appeals
Non-contracted providers have the right to file an appeal (reconsideration) within 65 days from the date of the denial notice or claims adjudication date on the Explanation of Payment (EOP). The non-contract provider can appeal for a post-service (claim) denial of payment or payment disputes where the claim was paid but the non-contracted provider disagrees with the amount that was paid out.
If you’re a non-contract provider, on your own behalf, you can file a standard appeal for a denied claim once you complete a waiver of liability (WOL) statement, which says you won’t bill the enrollee regardless of the outcome of the appeal. Pursuant to section 50.1.1 in CMS’ Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance(opens in a new window), HealthTeam Advantage will not accept an appeal request by a third party (such as a provider billing agency), as they cannot act on the provider’s behalf in the appeal process.
Claim appeals must be submitted in writing and should include the following documentation:
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- A completed waiver of liability form(opens in a new window)
- A copy of the submitted claim
- The denial notice
- All documents and documentation to support the justification for the appeal
- Good cause statement, if applicable*
Non-contracted provider claim appeals should be sent to:
HealthTeam Advantage
Attn: Appeals and Grievances
300 E Wendover Avenue, Suite 121
Greensboro, North Carolina 27401
or
Fax 800-845-4104
HealthTeam Advantage will not begin an appeal review until a valid and completed WOL statement is received. (CMS does not require health plans to begin a review until valid documentation is received.)
If the WOL is not received within the CMS claim appeal timeframe, the case will be dismissed by HealthTeam Advantage according to section 50.9 – Dismissals (Part C Only) within Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.
* Appeals that are submitted past the 65 calendar days must include a statement of good cause explaining why your level 1 appeal was not submitted in a timely fashion. A good cause statement must include:
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- Member name
- HealthTeam Advantage ID
- Date of service
- Claim number
- Reason for appeal submission past the 65-day time limit
A review will begin once the valid documentation is received with the appeal request.
New for 2027: Gap Exception Requests
Process Change Effective January 1, 2027: A Gap Exception Request is a request for a Medicare Advantage organization to treat an out-of-network provider as if they were in-network for a specific member, service, and period of time when the plan cannot reasonably provide access to an appropriate contracted provider.
An appropriate gap exception request may be made under the following circumstances:
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- No participating provider offers the required specialty or subspecialty.
- No participating provider can furnish the specific procedure or treatment.
- Network providers have excessive wait times that could adversely affect the member’s health.
- The nearest participating provider is beyond reasonable travel standards.
- The member requires continuity of care with a provider who possesses unique expertise not available in network.
- The plan’s network is otherwise inadequate for the requested service.
HealthTeam Advantage delegates gap exception requests to Cohere Health. If a request falls under the above listed circumstances, a request may be submitted via:
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- Online Portal: https://login.coherehealth.com/
- Faxing the prior authorization request form via fax to 844-873-3163.
- Calling 844-806-8217 option 3.
Single Case Agreements Requests
Single case agreements, are not gap exception request, requests for network access, gap exceptions, prior authorization, or organizational determinations. Prior authorization and gap exceptions must be submitted directly to Cohere Health.
A single case agreement is a written agreement between HealthTeam Advantage and a non-participating provider or facility that establishes reimbursement and other contractual terms for the provision of authorized services to a specific member when medically necessary covered services cannot be reasonably accessed through participating providers.
An SCA does not constitute network participation and is limited to the member, services, and time period specified in the agreement. Single Case Agreements are available only for non-participating providers and facilities; in-network providers are not eligible for Single Case Agreement consideration.
All requests for a single case agreements must be submitted on the plan’s request form, with all required supporting documentation. Incomplete requests will be delayed.
Requests may be submitted via secure email to credentialing@htanc.com or via fax to 800-853-9435.