Appeals post service: non-contracted provider
If you are a non-contracted provider making a post-service Medicare appeal, follow our standard payment reconsideration process outlined below.
Submit online (preferred)
For the fastest response, submit your dispute through prism within 60 calendar days from the date of the remittance advice. The required Waiver of Liability, stating the non-contracted provider won't bill the enrollee regardless of the outcome of the appeal, is included in this online process.
Note: This automated tool only allows you to submit the appeal for one individual claim at a time. If you need to submit multiple dates for the same member, each individual date of service must be appealed separately. This allows us to be CMS compliant and have the automated Waiver of Liability statement cover each claim that's being appealed.
- Log into your prism account.
- Click Appeals.
- Click New Post-Claim Appeal then on the claim number you want to appeal.
- On the Claims Detail page, click Contact us about this claim.
- Choose the appropriate dropdown option.
- Compose your message, completing all fields and attaching any relevant documentation.
- Click Send.
Your inquiry will appear in the General Requests section of prism after submission. You'll get an automated response with a claim inquiry reference number. A provider operations analyst will respond to your inquiry within 60 calendar days.
Or you mail / fax your dispute
Submit your appeal within 60 calendar days from the date of the remittance advice. Include a Waiver of Liability and send by mail or fax:
Priority Health Medicare Appeals
1231 E. Beltline Ave NE
Grand Rapids, MI 49525
Fax Number 616.975.8856
Priority Health Medicare will review your appeal and notify you in writing of our decision within 60 calendar days.
Medicare's Independent Review Entity
If Priority Health Medicare renders a partial or fully adverse decision, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare's Independent Review Entity (IRE). They will review the appeal within 60 calendar days to make sure the correct decision was made. You will receive correspondence by mail regarding their decision. If the IRE renders a favorable decision for you, Priority Health Medicare must effectuate and comply with the IRE's decision. A new Remittance Advice will be sent to reflect the IRE's decision.
For more information on Part C requirements for Provider Claim Appeals see section 50.1.1.
Frequently asked questions
What is the non-contracted provider appeal process for Priority Health Medicare?
A non-contracted provider can file a post service Medicare appeal for a denied claim with a Waiver of Liability, stating the non-contracted provider will not bill the enrollee regardless of the outcome of the appeal.
What is MAXIMUS Federal Services?
MAXIMUS Federal Services is an Independent Review Entity (IRE) Medicare uses to review cases to make sure the right decision was made. If Priority Health Medicare renders a partial or fully adverse decision, the appeal is automatically sent to the IRE.
What if a Waiver of Liability isn't submitted?
Priority Health Medicare will make reasonable attempts to obtain the Waiver of Liability (WOL) within the appeal timeframe. If Priority Health Medicare doesn't receive a WOL, the case will be dismissed as indicated in Section 50.9 of CMS' Parts C&D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance section.
What's the timeframe to submit a non-contracted provider Medicare appeal?
Non-contacted providers have 60 calendar days from the date of the Remittance Advice (RA) to submit a post service Medicare appeal. A Waiver of Liability (WOL) must be submitted with the appeal. The adjudication timeframe begins when the WOL is received by the plan.