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Provider Payment Dispute Resolution for Non-Contracted Providers

Medical Advantage Organizations, Section 1876 Cost Based Contractors, PACE Organizations and Health Care Prepayment Plans are required under sections 1852(k) and 1894(b)(3) of the Act and CMS regulations at 42 CFR §§422.214, 417.558 and 422.520, to reimburse non-contracted providers for services provided to Medicare beneficiaries no less than the amount that would be paid under original Medicare. Non-contracted providers are required to accept as payment, in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare. Plans should refer to the MA Payment Guide for Out of Network Payments in situations where they are required to pay at least the Medicare rate to out of network providers. A link to the guide can be found below.

In addition, CMS expects all MAOs and payers to act promptly to resolve payment disputes with non-contracted providers and to ensure that payments are made in accordance with the law.  In the event that a provider has difficulty accessing the plan’s dispute resolution process, s/he may file a complaint with 1-800-MEDICARE indicating that the plan’s internal dispute process has failed to resolve the issue. CMS Account Managers have been instructed to closely monitor MAOs’ actions in this regard and will take compliance actions as necessary.