HealthNet Medicare Advantage Provider Dispute Policy

HealthNet Medicare Advantage Provider Dispute Policy

Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) expanded its current provider payment dispute resolution process (PDR) for disputes between non-contracted and deemed providers and Private Fee for Service Plans (FFS) to include disputes between non-contracted providers and all:

• Medicare Advantage Organizations (HMO, PPO, RPPO and PFFS)
• 1876 Cost Plans
• Medi-Medi Plans (Medicare Medi-Cal Crossover)
• Program of All-Inclusive Care for the Elderly (PACE) organizations

This new regulation 1852 (a) (2) (A) the Act for Medicare Advantage plans relates to the claim dispute resolution practice.

First Level Provider Payment Disputes Subject to CMS PDR Process:  Includes decisions where a non-contracted  provider  contends that the amount paid for covered services is less than the amount that would have been paid under  original (traditional) Medicare.

Provider payment disputes may also include instances where there is a disagreement between a non-contracted provider and the organization about the plan’s decision to pay for a different service than billed, often referred to as down-coding of a claim.

First Level Appeals must be submitted in writing and must include:

• Provider name
• Provider  Tax ID #
• Meritage Medical Network claim transaction/claim number
• Complete Provider contact information
•  A clear explanation of the  dispute

First Level Appeals shall be addressed to:
Meritage Medical Network
Provider Dispute Intake Coordinator
4 Hamilton Landing, Suite 100, Novato, CA 94949
Attention: Medicare Advantage Provider Dispute Review

The dispute process does not include:

• Payment denials that result in zero payments
• Payment disputes for contracted providers
• Local and National Coverage Determinations
• Medical necessity determinations
• A non-contracting provider requesting payment in full
• Claims denied for timely filing
• Claims denied as not prior authorized
• Misdirected claim submissions

CMS PDR Filing Deadline for Submission:
Submission of a first level Provider Dispute must be filed within a minimum of 120 calendar days following the notice of initial determination. Meritage Medical Network will allow an additional 5 calendar days for mail delivery as a best practice standard for a total of 125 Calendar days.

Incomplete PDRs:

• In an effort to resolve all provider disputes in a timely manner, Meritage Medical Network will request additional information either in writing, by fax, or telephone.
• Providers have 14-calendar days to submit the requested information.
• Meritage Medical Network will resolve all PDRs within 30-calendar days, which includes the timeline for requesting additional information.
• If the requested information is not received within the required   timeframe, Meritage Medical Network will conduct the review based on the information in the file.
• If the requested information is received after we finalize the appeal, Meritage Medical Network will re-open the dispute.

Timeline for completion of Provider Disputes:

• Meritage Medical Network has 30-calendar days to process a Medicare Advantage Non-Contracted Provider dispute.  This 30-day period includes the time to process requested missing information.
• Meritage Medical Network will inform the provider in writing and must include all facts and rational pertaining to the resolution of the PDR.
•  Effective 02/2014:  Meritage Medical Network will inform provider about their right to CMS’ Provider Dispute Resolution (second level) process with Health Net.  

Demonstrating Good Cause for Late Filing:

When a non-contracted provider fails to meet the 120-day deadline for filing a PDR, the provider may resubmit the PDR with a “good cause” reason for late filing. When the provider fails to establish “good cause” for late filing, Meritage Medical Network may dismiss the dispute as untimely. In such cases, Meritage Medical Network will issue a resolution letter that explains the reason for dismissal and inform the non-contracted provider that they have up to 180- calendar days from the date of the dismissal letter to provide additional documentation for “good cause”. If a non-contracted provider submits evidence within 180- calendar days of dismissal that supports a findings of ‘good cause’ for late submission, Meritage Medical Network can make a favorable “good cause” determination, and issue a redetermination. If Meritage Medical Network does not find “good cause”, the dismissal remains in effect and Meritage Medical Network will issue a letter explaining that good cause had not been established.

Independent Payment Dispute- Second Level Review:

Following Meritage Medical Network’s final decision, the non-contracted provider may submit a second level written request for an Independent Payment Dispute Decision (PDD) to: Health Net, P.O. Box 10406, Van Nuys, CA 91410, within 180 calendar days of the written notice from Meritage Medical Network.

PDD requests may only be filed in the following two situations:

• The provider received an initial dispute decision from Meritage Medical Network’s internal dispute process and the provider disagrees with our decision.
• Meritage Medical Network did not finalize the dispute in 30 calendar days.

Once the Non-Contracted provider submits a (PDD),   Health Net  may request additional information from Meritage Medical Network.

Meritage Medical Network will send all requested information to Health Net within 7 calendar days via mail or fax to:

Second Level Appeals shall be addressed to:
Health Net
P.O. BOX 10406
Van Nuys, CA 91410

Health Net will issue a decision within 60 calendar days. When a PDD results in additional payment to the provider:

• Health Net will notify Meritage Medical Network in writing.
• Meritage Medical Network will then submit payment to the provider within 30 calendar days from the date of the PDD decision.
• Meritage Medical Network will send the Payment Dispute Confirmation Form to Health Net within 7 calendar days of payment.