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.