Information Last Updated: 10/1/2018
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.
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.
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.
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.
Examples: Bundling issues, disputed rate of payment, Diagnostic Related Groups (DRG) payment dispute, and down-coding.
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:
Examples: Benefit determinations, medical necessity issues, and coverage issues related to national and/or local coverage determination policies (NCDs/LCDs).
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. A signed WOL is required 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 will mail an acknowledgement letter to the non-contracted provider within 5 calendar days of receipt.
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.
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.
California Code of Regulations, Title 28, Section 1300.71.38
Provider Dispute Resolution for Medicare
Waiver of Liability Statement
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