1. CMS PDR 101
ICE Presentation 2014

2. CMS Provider Dispute Resolution
Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) will expand its current provider payment dispute resolution process for disputes between non-contracted and deemed providers and Private Fee for Service Plans to include disputes between non-contracted providers and all:
Medicare Advantage Organizations (HMO, PPO, RPPO and PFFS)
1876 Cost Plans
Medi-Medi Plans
Program of All-Inclusive Care for the Elderly (PACE) organizations.
Due to budgetary constraints, effective January 1, 2014, C2C will no longer be providing their services adjudicating provider disputes. C2C will adjudicate all payment disputes received by January 31, 2014, that meet the filing requirements. After January 31, 2014 C2C will return all provider disputes back to the provider, with the direction to contact the applicable MAO or designee.

3. First Level Provider Payment Disputes Subject to the CMS PDR Process:3
Includes decisions where a non-contracted provider contends that the amount paid by the payer for a covered service is less than the amount that would have been paid under Original Medicare.
See §§1852(a)(2)(A) of the Act for Medicare Advantage plans; 1876 for Cost plans; and 1866(a)(1)(O) for PACE organizations.
Provider payment disputes also include instances where there is a disagreement between a non-contracted provider and the payer about the plan’s decision to make payment on a more appropriate code (down coding).

4. CMS PDR Process Does Not Include:4
Payment denials by payers that result in zero payments being made to a non-contracted provider.
Payment disputes for contracted providers.
Local and National Coverage Determinations.
Medical necessity determinations.
Payment disputes for which no initial determination has been made.

5. CMS PDR Deadline for Submission
Submission of a first level Provider Dispute must be filed within a minimum of 120 calendar days after the notice of initial determination (i.e. EOB’s/ RA’s/ Letters).
Payer may allow an additional 5 calendar days for mail delivery.
Regulations at 42 CFR
The payer may extend the time limit for filing a provider dispute if good cause is shown.

6. Extension of Time Limit for Filing a CMS Provider Dispute – Good Cause
When a provider or supplier has failed to establish a good cause for late filing of a provider dispute, the payer dismisses the provider dispute as untimely filed.
Resolution must explain the reason for dismissal and that the provider or supplier has up to 180 calendar days from the date of the dismissal notice to provide additional documentation for good cause.
If provider or supplier submits evidence within 180 calendar days of dismissal that supports a finding of good cause for late filing, the payer makes a favorable good cause determination and issues a redetermination.
If the payer does not find good cause, the dismissal remains in effect and payer issues a letter or EOB/RA explaining that good cause has not been established.

7. Requesting Documentation for Review of the CMS Provider Dispute
When necessary documentation has not been submitted for review of the Provider Dispute, the payer advises the provider to submit the required documentation.
Request can be made via phone or in writing.
If the additional documentation that was requested is not received within 14 calendar days from the date of request, the payer conducts the review based on the information in the file.
In the event that the documentation is received after the 14 calendar day deadline, the payer must consider the evidence before making and issuing the final determination.
PLEASE NOTE: THE CMS PROVIDER DISPUTE MUST BE RESOLVED WITHIN 30 CALENDAR DAYS FROM RECEIPT.

8. Time Frame for Making a CMS Payment Dispute Decision:8
Payers decision on the Payment Dispute must be within 30 calendar days from the date the Payment Dispute is first received by the payer.
Must be in writing
Include facts and rational pertaining to the resolution
Inform provider about their right to the MAO-Health Plan or designee, Provider Dispute Resolution (Second Level) review process.

9. CMS Provider Dispute Resolution Letter Format
Provider Dispute correspondence shall follow these recommended guidelines:
Use at least 12 point font/type
Use an easy to read font style; for example Universal or Times New Roman
If procedure codes are cited, the actual name of the procedure must be associated with the code – services should not be abbreviated

10. CMS PDR: Payment of Interest
Effective May 1, 2011; CMS Region IX has reviewed its policy with respect to payment of interest on disputed claims, including claims from non-contracted providers. Interest must be paid on such claims in the same manner as provided for all other claims. If the original claim was underpaid in error, then interest would be required on the additional amount of the payment due, from the date of the original claim until the date the claim was reprocessed. Interest would be calculated in the same manner as interest on all claims, which is discussed in the Medicare Claims Processing Manual, Section 80.
Additional information on the calculation of late interest penalties including examples can be accessed on the Prompt Pay Web site at

11. Second Level Independent Payment Dispute Resolution11
The non-contracted provider may submit a second level written request to the applicable MAO-Health Plan or designee for a second level review, by , fax or mail within 180 calendar days of written notice from the payer.
The PDD request may be filed if:
30 calendar days has elapsed from the date the payer received the dispute and the payer has not responded.

12. Second Level Independent Payment Dispute Resolution Review Process – will depend on MAO.12
Once the Provider Payment Dispute is requested, the MAO-Health Plan or designee may request documentation from the payer that processed the first level provider dispute.

13. CMS PDR: Retaining Documents and Records
Copies of all provider disputes and corresponding documentation must be kept for a period of not less than ten years.
42 C.F.R §

14. ICE Provider Dispute Resolution Request Form

15. CMS PDR Overturn Resolution Letter

16. CMS PDR Uphold Resolution Letter

17. ICE CMS Provider Payment Dispute Resolution Workflow

18. ICE CMS PDR Audit Worksheet

19. Delegated Payer Must Ensure:
Payers internal payment dispute process for non-contracted providers is well defined.
Develop written policy and procedure.
Information on submitting first level internal payment disputes to the payer is communicated to the non-contracted provider.
Payers website should have the CMS Provider Dispute Resolution Process detailed with timeframes, forms and 2nd level appeal process stated.
Appeals information is communicated to the non-contracted provider via:
Explanation of Benefits or Remittance Advise

20. Delegated Payer Must Ensure: Continued
All areas of the organization are aware of the internal payment dispute process including customer service, claims and appeals staff.
First-level internal payment dispute decisions inform non-contracted providers about their right to CMS’ provider payment dispute resolution process (second level – MAO-Health Plan or designee).
As a best practice, forward all misdirected CMS Provider Disputes to correct payer within 8 – 10 calendar days from receipt.
CMS provider disputes must be tracked in a manner allowing
linkage with payer’s original claim number.