Appeal tips for non-contracted Medicare providers

Are you a non-contracted Medicare provider? Do you disagree with how a claim was processed? You must submit an appeal through prism, our online provider portal.

Why do I need to submit an appeal?

To make sure we remain in compliance with CMS policy, we can’t simply reprocess disputed Medicare claims for non-contracted providers. This is because non-contracted providers must include a signed Waiver of Liability (WOL) with any reconsideration request for a Medicare claim, ensuring they won’t bill the member regardless the outcome.

How do I submit an appeal?

We highly recommend submitting appeals through prism, our online provider portal. All providers, contracted and not, can have a prism account. Submitting through prism, rather than via fax, with ensure the fastest response.

For details on both the prism and fax processes, visit the Appeals post service: Non-contracted provider webpage.

What if I just have a question about how a claim was processed?

If you’re simply wondering why a claim was denied, want us to explain a clinical edit that was applied to your claim or have another question about how your claim was processed, you can submit your question to our teams through prism’s Claims Inquiry or General Requests features. You can also call our Provider Hotline.

However, if you disagree with the outcome of your inquiry, you’ll need to submit an appeal.