These guidelines establish when Health New England (HNE) must accept Non-Contract Provider appeals. Non-Contract Providers are providers that are not participating in the HNE Medicare Advantage product but who have provided services to a Health New England Medicare Advantage member. If HNE Medicare Advantage denies a request for payment, in whole or in part, from a Non-Contract Provider, HNE Medicare Advantage shall notify the Non-Contract Provider of the specific reason for the denialand shall provide a description of the appeals process.
When a Non-Contract Provider submits an appeal of a denial of payment, HNE Medicare Advantage must verify the following information prior to processing the appeal:
- Was the appeal submitted within 60 days of receipt of the Explanation of Payment notice?
- Was the appeal accompanied by a completed Waiver of Liability Statement (WLS)?
- If the appeal was submitted after 60 days, according to Medicare guidelines,1 the appeal is not eligible for consideration and should be dismissed. In this instance, the Non-Contract Provider will receive written notice of the dismissal from HNE Medicare Advantage but may request further review by the Independent Review Entity listed below:
MAXIMUS Federal Services, Inc.
Medicare Managed Care & PACE Reconsideration Project
3750 Monroe Avenue, Suite 702
Pittsford, MY 14534-1302
Fax: 585.425.5292
- If the appeal was submitted within the 60 days, the appeal must also be accompanied by a WLS by which the Non-Contract Provider agrees to hold the member harmless even in the event the health plan denies the appeal.
- If the WLS is not received with the appeal, HNE Medicare Advantage will notify the Non-Contract Provider of the missing WLS is writing.
- The Non-Contract Provider is still obligated to submit the WLS within the original 60 days from the date they received the Explanation of Payment notice, not 60 days from receiving the notice indicating a WLS is still needed to process the appeal.
- If the WLS is received within the 60 day timeframe, then HNE Medicare Advantage will process the appeal and notify the Non-Contract Provider of the outcome. In the event the WLS is either not received or not received within the specified timeframe, the Non-Contract Provider will receive written notice of the dismissal from HNE Medicare Advantage but may request further review by the Independent Review Entity listed below:
MAXIMUS Federal Services, Inc.
Medicare Managed Care & PACE Reconsideration Project
3750 Monroe Avenue, Suite 702
Pittsford, MY 14534-1302
Fax: 585.425.5292
1
See the Medicare Managed Care Manual , Chapter 13, “Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans),” Sections 40.2.3 and 60.1.1.