Appeals tips for Medicare non-contracted providers

If you’re a non-contracted provider making a post-service Medicare appeal, below are a few tips, tricks and key pieces of information from our Reimbursement team to help you navigate the two levels of the Medicare Appeals process.

What’s an appeal/reconsideration?

The first level of the Medicare Appeals process, an appeal / reconsideration is a challenge to a denial or decision to pay for a different service or pay at a different level of service than you originally billed.

We may deny benefits or payment due to:

  • Benefit determinations
  • Medical necessity issues
  • Coverage issues related to National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs)

Timeframe to appeal

Claim appeals

If you aren’t contracted with Priority Health Medicare Advantage and you disagree with a denial on a claim (either in part or in whole), you have 60 calendar days from the initial denial date to file an appeal – also known as a reconsideration.

Reimbursement appeals

Reimbursement appeals do not fall under this process and are processed as a normal Provider Appeal (ie – we paid the claim, but you disagree with the allowed amount). These appeals must be filed within 180 days of the initial claim processing date.

How to file an appeal

Online, the easiest and preferred way

All providers, whether contracted with us or not, must submit appeals through prism, our online provider portal. Through prism, you can easily status claims, make inquiries and file appeals. We’ll communicate with you about these types of requests directly through your prism account.

Create your prism account

In writing, via mail or fax

You may also submit your appeal in writing through the mail or via fax:

Priority Health

1231 E Beltline Ave NE

Grand Rapids, MI 49525

Fax: 616-975-8856

Waiver of Liability (WOL)

As a non-contracted provider, you’re required by the Centers for Medicare & Medicaid Services (CMS) to submit a Waiver of Liability (WOL) form with your appeals. This ensures your patient, our member, is held harmless regardless of the appeal’s outcome. We can’t and won’t review an appeal without a valid WOL form.

When you submit an appeal through prism, we’ll prompt you to complete the WOL and provide you the form at that time.

If you choose to file your appeal in writing, you can find a blank WOL here.

Timeframe for review

Once we receive your appeal with a valid WOL, we have 60 calendar days from the date of receipt to decide.

Favorable decision

If we agree with you, we’ll approve the appeal, and you’ll receive a decision letter with what to expect for claims adjustment.

Denied decision

If we disagree with you, we’ll deny your appeal, and you’ll receive a decision letter which will include that we’re submitting the appeal to an Independent Review Entity (IRE)

Independent Review Entity (IRE)

This is the second level of the Medicare Appeals process. If we deny your appeal, CMS requires us to submit the appeal to the IRE. Medicare hires the IRE review our appeal decisions. The IRE will perform their own independent review and will either disagree with us and overturn our denial, or they’ll agree with us and also deny the appeal.

Like us, the IRE will have 60 calendar days to review your appeal. They’ll provide their decision notices directly to you – they won’t come from us.