The Centers for Medicare & Medicaid Services(CMS) current provider payment dispute resolution process (PDR) for disputes between non-contracted and deemed providers and Private Fee for Service Plans (FFS):
- Medicare Advantage Organizations (HMO, PPO, RPPO and PFFS)
- 1876 Cost Plans
- Medi-Medi Plans
- Program of All-Inclusive Care for the Elderly (PACE) organizations
The following document outlines the CMS Non-Par Provider Payment Dispute Resolution Process:
The following sample letters provide details on Hill Physicians’ compliance with this program:
Waiver of Liability Statement Form for Non-Par Providers:
Commercial and Medi-Cal Provider Dispute Resolution Process
Definition of Provider Dispute: A Provider Dispute is a provider’s written notice to Hill Physicians and/or the Enrollee’s Health Plan challenging, appealing or requesting reconsideration of a claim for the following reasons:
- A claim has been denied.
- A claim has been adjusted.
- A claim has been adjudicated in a way that conflicts with the Hill Physicians Provider’s contract, including reimbursement rates
- The provider has received a request for repayment of a claim that was overpaid
The following document outlines the Commercial and Medi-Cal Provider Dispute Resolution Process:
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