CMS non-contracted provider appeal process

Non-contracted providers have the right to request a CMS appeal for denial of payment (zero pay) within 60 calendar days from the remittance notification date. 

A signed waiver of liability form holding the enrollee harmless regardless of the outcome of the appeal is required and must be sent in with all CMS appeal requests.

See the Medicare Managed Manual (MMCM) and waiver of liability form.

CMS waiver of liability form 

A signed form holds the enrollee harmless regardless of the outcome of the appeal.

View form

Information on CMS appeals

When submitting a CMS appeal/reconsideration request, you must include all pertinent documentation to support your appeal.

This can include: 

• A copy of the original claim
• Remittance notification showing the denial
• Any clinical records or other documentation that supports your argument for reimbursement

Please keep in mind that if the waiver of liability is not received along with all supporting documentation when sent to the health plan, your case may be sent for dismissal.

Please submit all CMS appeal and reconsideration requests to the addresses below for the following health plans:

All other reconsideration requests should be sent to Optum:

Provider Dispute Resolution Department
P.O. Box 6902
Rancho Cucamonga, CA 91729-6902