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MA PAP233

Medicare Advantage Payment Dispute Resolution Process for Non-Contracting Providers


Provider Administrative Policy

Section
Provider Information
Policy Date
March 2009
Status/Date
Revised/December 2013

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts


Policy

Medicare Advantage Payment Dispute Resolution Process for Non-Contracting Providers

Please note:  This policy applies to non-contracting providers.

If you believe the payment made for a service is less than the amount allowed in our terms and conditions, you  have the right to dispute under our dispute resolution process. 

Decisions Subject to the Payment Dispute Resolution Process

Non-contracting providers may dispute the payment amount issued by the Medicare Advantage plan if the provider believes the plan paid less than would have been allowed under traditional Medicare rates.

Decisions Not Subject to the Payment Dispute Resolution Process

1. Services denied for coverage issues such as Local Coverage Determinations (LCDs)

2. National Coverage Determinations (NCDs)

3. Medical necessity determinations

4. Disputes between a contracted Medicare Advantage provider and the Medicare Advantage plan (see MA PAP 229)

For questions about the dispute resolution process, call us at 208-286-3656 or 888-482-2250 or send written disputes to:

Blue Cross of Idaho Provider Appeals
P.O. Box 7408
Boise, Idaho 83707

Provide supporting documentation for your payment dispute (A remittance advice from a Medicare carrier would qualify). You must dispute a claim within 120 days of the date you initially receive payment. 

We will review your dispute and respond within 30 days of the date that we receive the dispute. If we find in your favor, we will pay the additional amount due. You will receive notification in writing if we deny your dispute.

If after completing the dispute resolution process, you believe we have reached an incorrect decision, you may request a review by C2C Solutions Inc., an independent entity contracted by the Centers for Medicare and Medicaid Services (CMS).

Effective January 1, 2014, C2C will no longer review payment disputes from non-contracting providers. C2C will adjudicate all payment disputes received by January 31, 2014 that meet the filing requirements. After that date, C2C will return to providers any payment disputes received after January 31, 2014.

In the event that Blue Cross of Idaho's internal dispute process has failed to resolve the issue, the provider may file a complaint with 1-800-Medicare.

For payment disputes prior to January 31, 2014, contact C2C directly via one of the following methods:

1. Email - If the review and any associated documents contain no personally identifiable health information (PHI) or if you redact any PHI, you can submit the review request via email to PDRC@C2Cinc.com.
 
Otherwise, send dispute review requests (including associated documents such as claims forms that contain PHI) via fax or mail.
 
2. Fax: 904-361-0551

3. Mail:
C2C Solutions, Inc.
Payment Dispute Resolution Contractor
P.O. Box 44017
Jacksonville, FL 32231-4017

ALL REQUESTS SHOULD INCLUDE A PAYMENT DISPUTE DECISION (PDD) REQUEST FORM OR AT LEAST ALL OF THE INFORMATION ELEMENTS CONTAINED THEREIN 

Payment Dispute Decision (PDD) Request Form

 

For questions regarding the dispute review process or disputes currently under review contact C2C Solutions, Inc., at 904-791-6430. Providers and MA plans should expect a return call within 48 hours of leaving a message. Send hard copy correspondence associated with a dispute review request to:
 
C2C Solutions, Inc.
Payment Dispute Resolution Contractor
P.O. Box 44035
Jacksonville, FL 32231-4035


Policy History

Date Action Reason
December 2013 Revised Updated process per CMS changes
September 2012 Revised Removed references to 'deemed providers' since Flexi-Blue is no longer offered.
August 2010 Revised Includes all Medicare Advantage products for non-contracting providers

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