Provider Payment Dispute Resolution for Non-Contracted Providers

CMS has established an independent provider payment dispute resolution process for disputes between non-contracted providers and all Medicare Advantage (MA) Organizations (HMO, PPO, RPPO and PFFS), 1876 Cost Plans, and the Program of All-Inclusive Care for the Elderly (PACE) organizations. This page provides information and resources for MA organizations and providers to assist them in this process.

Provider payment disputes subject to this independent review process include any decisions where a non-contracted provider contends that the amount paid by the MA organization for a covered service is less than the amount that would have been paid under original Medicare. Disputes subject to the resolution process also include instances where there is a disagreement between a non-contracted provider and the MA organization about the plan's decision to pay for a different service than that billed, often referred to as down-coding of claims. CMS recently issued an update to the Medicare Advantage Payment Guide for Out of Network Payments that provides additional guidance to MA organizations on making payments to non-contracted providers.

Independent review of a provider payment dispute is available only after a provider has completed the plan's first-level appeals process and the MA organization has informed the provider in writing that the payment dispute has been denied. Upon receiving the dispute decision from the MA organization, a provider may request a review of that decision by CMS' Payment Dispute Resolution Contractor (PDRC). The PDRC is C2C Solutions, Inc (C2C). CMS awarded the contract to First Coast Service Options, Inc. (FCSO) and the task order has been administered by C2C under a special power of attorney pending CMS novation approval. In July 2010 CMS approved the novation of the task order to C2C.

To request an independent review of a payment dispute decision, the provider must submit a written request for a Payment Dispute Decision to the PDRC by e-mail, fax, or mail. The PDRC must receive this request within 180 days of the MA organization's written notice of the unfavorable dispute decision. Please refer to the PDRC's web site for details on the request submission process. The PDRC will notify all parties of its decision in writing within 60 days of receiving a request for a dispute decision.