Part C Non-Contracted Provider Claim Appeals
The Centers for Medicare and Medicaid (CMS) regulations for Medicare Advantage plans, provide non-contracted providers the right to file an appeal (reconsideration) for a post-service (claim) denial of payment (for more information, see the most current version of Chapter 13 https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/index.html).
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.
A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal.
Non-Contracted Providers have 60 calendar days from the date of the denial notice to file an appeal.
Claim appeals must be submitted in writing and should include the following documentation:
- a completed WOL
- a copy of the submitted claim
- the denial notice
- all documents and documentation to support the justification for the appeal
An appeal review will not commence until a valid and completed Waiver of Liability (WOL) statement is received by the Plan. The Plan is not required by CMS 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 Plan according to the updated guidance, amending Chapter 13, released by CMS September 10, 2013 and October 30, 2013 – Part C Reconsideration Dismissal Procedures.
A review will begin once the valid documentation is received with a new appeal request.
How to request a Non-Contracted Provider Claim Appeal?
Attn: Appeals and Grievances
7800 McCloud Road, Suite 100
Greensboro, NC 27409