Part C Non-Contracted Provider Claim Appeals

Non-contracted providers have the right to file an appeal (reconsideration) within 60 days from the date of the denial notice or claims adjudication date on the Explanation of Payment (EOP). The non-contract provider can appeal for a post-service (claim) denial of payment or payment disputes where the claim was paid but the non-contracted provider disagrees with the amount that was paid out.

If you’re a non-contract provider, on your own behalf, you can file a standard appeal for a denied claim once you complete a waiver of liability (WOL) statement, which says you won’t bill the enrollee regardless of the outcome of the appeal. Pursuant to section 50.1.1 in CMS’ Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance, HealthTeam Advantage will not accept an appeal request by a third party (such as a provider billing agency) as they cannot act on the provider’s behalf in the appeal process. Claim appeals must be submitted in writing and should include the following documentation:

• A completed waiver of liability form
• A copy of the submitted claim
• The denial notice
• All documents and documentation to support the justification for the appeal
• Good cause statement, if applicable*

Non-contracted provider claim appeals should be sent to:

HealthTeam Advantage                           or             Fax 800-845-4104
Attn: Appeals and Grievances
300 E. Wendover Ave. Suite 121
Greensboro, NC 27401

HealthTeam Advantage (HTA) will not begin an appeal review until a valid and completed WOL statement is received. (CMS does not require health plans to begin a review until valid documentation is received.)

If the WOL is not received within the CMS claim appeal timeframe, the case will be dismissed by HTA according to section 50.9 – Dismissals (Part C Only) within Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.

* Appeals that are submitted past the 60 calendar days must include a statement of good cause explaining why your level 1 appeal was not submitted timely. A good cause statement must include:

• Member name
• HealthTeam Advantage ID
• Date of service
• Claim number
• Reason for appeal submission past the 60-day time limit

A review will begin once the valid documentation is received with the appeal request.