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Provider Dispute Resolution for Medicare

Information Last Updated: 10/1/2018

Policy Statement

Universal Care dba Brand New Day is committed as a company to adhering to State and Federal laws, regulations, and guidance from the Centers for Medicare and Medicaid Services (CMS), the California Department of Managed Health Care (DMHC), and the California Department of Health Care Services (DHCS) in order to provide excellent service and care while preventing and correcting any fraud, waste, or abuse. Universal Care dba Brand New Day additionally is dedicated to improving the quality of care for members by following guidance published by the National Committee for Quality Assurance and other accrediting bodies.

Universal Care dba Brand New Day maintains a fast, fair, cost effective Provider Dispute Resolution (PDR) process for contracting and non-contracting providers per Medicare guidelines of the Centers for Medicare and Medicaid Service (CMS). Providers wishing to file a dispute are not subject to discrimination or retaliation. In processing provider disputes, Universal Care dba Brand New Day does not charge the provider for costs incurred and does not reimburse for expenses incurred by the disputing provider. All provider disputes must be received in writing and must be filed timely per Medicare guidelines.

Purpose

This policy to outlines the Prover Dispute Resolution (PDR) process for Non-Contracted Providers to ensure each mechanism complies with Section 1300.71.38 of Title 28.

Scope

Whenever a non-contracted provider claim is denied, contested, or adjusted (claim not paid at 100% of billed charges), Brand New Day will inform the non-contracted provider in writing of the availability of the claim payment dispute resolution (PDR) and/or claim payment appeal (reconsideration) mechanisms and the procedures for obtaining forms and instructions for filing a non-contracted provider dispute and/or appeal.

This process is available for use by non-contracted providers who disagree with Brand New Day’s initial Organization Determination.

Please note: Contracted providers follow state processes and the contracted provider’s agreement/contract with Brand New Day and/or the Brand New Day state Provider Manual guidelines as appropriate.

Definitions

PDR - Provider Dispute Resolution
DRG - Diagnostic Related Groups
EOB - Explanation of Benefits
RA - Remittance Advices

Procedure

  1. How to Determine if the Case Should be Submitted as a Dispute or an Appeal

    1. Dispute/PDR — Is any decision by Brand New Day (Organization Determination) that results in a full or partial payment to a non-contracted Medicare provider where the non-contracted provider disagrees with the decision.

      1. Where the amount paid for a Medicare-covered service is less than the amount that would have been paid under Original Medicare.
      2. Where Brand New Day paid for a different service or more appropriate code than what was billed. Often referred to as a down-coding of claims.

      Examples: Bundling issues, disputed rate of payment, Diagnostic Related Groups (DRG) payment dispute, and down-coding.

    2. Appeal/Reconsideration — An appeal is a formal complaint related to denial of a claim by Brand New Day (adverse Organization Determination) and can be for:

      1. Denials that result in zero payments to the non-contracted provider.
      2. Medical necessity determinations.
      3. Appeals for which no initial determination has been made.
      4. Local and national coverage determinations.

      Examples: Benefit determinations, medical necessity issues, and coverage issues related to national and/or local coverage determination policies (NCDs/LCDs).

  2. Submission Guidelines for Non-Contracted Provider Disputes and Appeals

    1. Please make note the following in order to avoid delays in processing; incomplete submissions will affect processing. Include supporting documentation.

    For an appeal the non-contracted provider MUST sign and submit a Waiver of Liability (WOL) Statement before Brand New Day can begin processing the appeal. If a WOL is not received, the appeal will be forwarded to MAXIMUS Federal Services, Inc. to request a dismissal. A signed WOL is not needed for disputes.

    Corrected claims should NOT be submitted as a dispute or appeal. They are considered a corrected/new claim and should be sent to Brand New Day's Claims Department for an initial Organization Determination and not processed as a dispute or appeal. Corrected/New claims should be mailed to:

    Brand New Day
    P.O. Box 93122
    Long Beach, CA 90809
     
  3. Address for Submitting a Non-Contracted Provider Dispute or Appeal

    1. Non-contracted providers must mail a written request to Brand New Day's state-level Provider
    2. Dispute and Appeals Unit:

       

      Brand New Day
      Provider Dispute Resolution
      P.O. Box 93122
      Long Beach, CA 90809

       

    3. Clearly indicate whether you are submitting a dispute (when full or partial payment was made on the initial Organization Determination) or an appeal (when zero payment was initially made).
  4. Deadlines for Submitting Non-Contracted Provider Disputes and Appeals

    1. Dispute/PDR120 calendar days from the initial Organization Determination date (i.e., EOB/RA/determination letter) to file a written request for a dispute with Brand New Day.
    2. Appeal/Reconsideration — Non-contracted providers have 60 calendar days from the initial adverse Organization Determination date (i.e. EOB/RA/determination letter) to file a written request for an appeal with Brand New Day.
  5. Acknowledgment of Non-Contracted Provider Disputes and Appeals

    Brand New Day will mail an acknowledgement letter to the non-contracted provider within 5 calendar days of receipt.

  6. Resolution Timeframe for Non-Contracted Provider Disputes and Appeals

    Brand New Day will resolve each non-contracted provider claim payment dispute (PDR) within 30 calendar days of receipt of the written request. Claim payment appeals will be resolved within 60 calendar days of receipt.

  7. Non-Contracted Provider Second Level Independent Review Entity Process Appeal/Reconsideration

    If Brand New Day upholds the initial claim decision, Medicare requires that Brand New Day send all cases where we have not changed our decision to an independent review entity. MAXIMUS Federal Services, Inc. will contact the non-contracted provider to advise where to send any additional information and about other rights that the non-contracted provider may have.

Reference

California Code of Regulations, Title 28, Section 1300.71.38
P&P 600-B-053
Provider Dispute Resolution for Medicare

Waiver of Liability Statement

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