Provider Dispute Resolution Process

CMS Non-Par Provider Payment Dispute Resolution Process

The Centers for Medicare & Medicaid Services(CMS) current provider payment dispute resolution process (PDR) for disputes between non-contracted and deemed providers and Private Fee for Service Plans (FFS):

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

The following document outlines the CMS Non-Par Provider Payment Dispute Resolution Process:
Non-Par Provider Payment Dispute Resolution Process

The following sample letters provide details on Hill Physicians' compliance with this program:
CMS PDR Letter - Request for Additional Information
CMS PDR Letter - Adjustment Payment Made
CMS PDR Letter - Upheld
CMS PDR Letter - Late Submission
CMS PDR Letter - Closure for Non-Receipt

Waiver of Liability Statement Form for Non-Par Providers:
CMS Waiver of Liability Statement

Commercial and Medi-Cal Provider Dispute Resolution Process

Definition of Provider Dispute: A Provider Dispute is a provider's written notice to Hill Physicians and/or the Enrollee's Health Plan challenging, appealing or requesting reconsideration of a claim for the following reasons:

  • A claim has been denied.
  • A claim has been adjusted.
  • A claim has been adjudicated in a way that conflicts with teh Hill Physicians Provider's contract, including reimbursement rates
  • The provider has received a request for repayment of a claim that was overpaid

The following document outlines the Commercial and Medi-Cal Provider Dispute Resolution Process: Provider Dispute Resolution Process