1. Non-Contracted Provider Payment Appeals and Claim Disputes

NON-CONTRACTED PROVIDER PAYMENT APPEALS AND CLAIM DISPUTES

Payment Appeal – A challenge or an ‘appeal’ related to benefit/payment denials by the Medicare health plan that results in zero payment being made to the non-contracted Medicare health plan provider. Examples include:

  • Benefit Determinations
  • Medical necessity issues
  • Coverage issues related to nation and/or local coverage determination policies

Claims Payment Dispute – Any decision where a non-contracted Medicare health plan provider contends that the amount paid by the Medicare health plan for a Medicare covered service is less than the amount that would have been paid under original Medicare. Non-contracted provider claim payment disputes also include instances where there is a disagreement between a non-contracted Medicare health plan provider and the Medicare health plan about the plan’s decision to pay for a different service or level than that billed.

Examples include:

  • Bundling
  • Disputed rate of payment
  • DRG payment
  • Downcoding

Payment Appeal Rights ‍

In accordance with the Medicare managed care regulations, non-contracted providers have Medicare appeal rights for any claims denied by PrimeTime Health Plan. All requests for payment appeals must include a completed and signed “Waiver of Liability” (WOL) form holding the enrollee harmless regardless of the outcome of the appeal. PrimeTime Health Plan cannot begin the appeals process until a completed and signed Waiver of Liability Form is received. If the WOL is not received within 60 days of the initial request, PrimeTime Health Plan will dismiss the appeal in accordance with Medicare rules.

Waiver of Liability Form (WOL): Waiver of Liability Statement

Requests for payment appeals must be filed within 60 calendar days of the payment decision date. The request should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s argument for reimbursement. PrimeTime Health Plan must make a decision regarding the appeal within 60 calendar days from the date the appeal request was received. Review Requests should include the member name, your provider address, member identification number, date of initial determination, dates of service, appeal reason and any additional evidence you wish to include and be sent to the below address.

PrimeTime Health Plan

Attn: Appeals Department

P.O. Box 6029

Canton, OH 44706

If PrimeTime Health Plan upholds the initial payment denial, the plan is required to submit the appeal request to the CMS Independent Review Entity (IRE) for a second level review. The current IRE for payment appeals is Maximus Federal Services. The IRE will review the appeal and notify the provider in writing of the decision.

Claims Payment Dispute Rights

In accordance with Medicare managed care regulations, non-contracted providers have Medicare payment dispute rights. Medicare payment dispute rights apply to any claim for which the provider contends the amount paid by PrimeTime Health Plan for a covered service is less than the amount that would have been paid by Original Medicare. Medicare payment dispute rights also apply to any claim for which there is a disagreement between the non-contracted provider and PrimeTime Health Plan regarding the plan’s decision to pay for a different service than the billed service. Payment disputes must be filed within 180 calendar days of payment decision date and the plan must make a decision regarding the dispute within 30 calendar days from the date the payment dispute was received.

CMS expects Medicare Advantage organizations such as PrimeTime Health Plan to pay non-contracted providers the same amount the provider would have received had the provider billed Original Medicare.

The non-contracted provider payment dispute process cannot be used to challenge payment denials by PrimeTime Health Plan that result in zero payment being made. Payment denials may be appealed as described in the Payment Appeal Rights section above.

NOTE: ADDITIONAL INFORMATION ABOUT THE APPEALS AND PAYMENT DISPUTE PROCESSES CAN BE PROVIDED BY CALLING CUSTOMER SERVICE AT 800-577-5084.