Non-Contracted Provider Appeals
Effective: January 1, 2010
CMS established an independent provider payment resolution process for disputes between non-contracted providers, Medicare Advantage (MA) Organizations, Cost Plans, and the Program of All-Inclusive Care for the Elderly (PACE) plan.
New Dispute Process Part C Claims Applies To:
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- Non-contracted providers contending the amount AAHP paid for a covered service was less than the amount Original Medicare would have paid.
- When a non-contracted provider disagrees with AAHP about its decision to pay for a different service than billed (known as down coding) and claims with bundled codes.
The Provider Dispute Process CAN'T be Used:
- To challenge payment denials by organizations that result in zero payment being made to the non-contract provider. Instead, these matters must be processed as appeals under 42 CFR subpart M.
- To resolve payment disputes between contracted network providers and organizations covered by this process.
How to Use the Payment Dispute Process
Submit a Dispute in Writing & Send to:
Abrazo Advantage Health Plan (HMO)
Appeals Department/ Request for Payment Determination
7878 North 16th Street, Suite 105
Phoenix, Arizona 85020
The Payment Dispute Process:
1st Level Dispute
AAHP will process the dispute if it meets the criteria and make a Payment Review Determination either upholding or reversing the organizational determination.
2nd Level Dispute
If the dispute is upheld, you can request an independent review.
Request an Independent Review
Submit directly to CMS's payment dispute resolution contractor, C2C Solutions, Inc.
Things to Remember
Submissions must be submitted within 180 calendar days from the date you received AAHP's decision in its Notice of Payment Review.
Submissions must follow the process outlined on CMS's Payment Dispute Resolution Contractor Process Manual.
Obtain a Copy Below:
Mail Your Submissions To:
C2C Solutions, Inc.
Payment Dispute Resolution Contractor
P.O. Box 44017
Jacksonville, Florida 32231-4017
Phone/Fax/Web:
Phone (904) 791-6430
Fax: (904) 361-0551
www.C2Cinc.com
What Happens Next
C2C Solutions will render a decision within 60 days after receiving a valid Payment Dispute Appeal.
a. If C2C Solutions overturns AAHP's decision, AAHP will effectuate payment within thirty (30) days from the date of the C2C's decision.
C2C'sdecision is final. You may request a debriefing and explanation of the C2C's decision if a request is made within 14 days of the decision.
b. If the dispute if overturned, AAHP will process payment within sixty (60) days from the date AAHP is notified by C2C to reprocess the claim.
Please note providers using an appointed representative to file an appeal (groups & organizations are prohibited) must provide written and signed authorization designating the individual as the provider's representative.
Requests that do not contain all required elements are considered incomplete and subject to dismissal. Please review the CMS Payment Dispute Resolution Contractor Process Manual for further details.