Part C Non-Contracted Provider Claim Appeals

Non-contracted providers have the right to file an appeal (reconsideration) for a post-service (claim) denial of payment, per The Centers for Medicare and Medicaid (CMS) regulations for Medicare Advantage plans within 60 calendar days* from the date of the denial notice.

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, 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:

• A completed waiver of liability form
• 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                           or         Fax 800-845-4104
Attn: Appeals and Grievances
7800 McCloud Road, Suite 100
Greensboro, NC 27409

HealthTeam Advantage (HTA) won’t begin an appeal review until a valid and completed WOL statement is received. (CMS doesn’t 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 HTA 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 60 calendar days must include a statement of good cause explaining why your level 1 appeal was not submitted timely. A good cause statement must include:

• Member name
• HealthTeam Advantage ID
• Date of service
• Claim number
• Reason for appeal submission past the 60-day time limit

A review will begin once the valid documentation is received with the appeal request.

The non-contract appeal process does not include disputes where the claim was paid but the non-contracted provider disagrees with the amount that was paid out. Those disputes are handled through the Provider Dispute process.