CMS provider disputes

According to federal regulations that govern Medicare Advantage plans, non-contracted providers may file a payment dispute for a Medicare Advantage plan payment determination.

A payment dispute may be filed when the provider disagrees with the amount paid. This includes issues related to bundling of services.

To dispute a claim payment, submit a written request within 120 days of the remittance notification date and include, at a minimum:

• A statement indicating factual or legal basis for the dispute
• A copy of the original claim
• A copy of the remittance notice showing the claim payment
• Any additional information, clinical records or documentation to support the dispute
• Dispute form
  

If you have more questions about a dispute decision, contact us at:

Phone: 1-800-956-8000
Fax: 1-866-929-7165
Mail: PDR Department
P.O. Box 6902
Rancho Cucamonga, CA 91729-6902

If you do not agree with the dispute determination, you can request a Health Plan dispute review. A dispute review must be received within 120 days from the determination date of the initial dispute.

HMO addresses

Send dispute requests in writing and include all documentation to support your position. Send them to the Provider Appeals and Disputes team at the HMO addresses listed below.