CMS has not established a process by which a provider who is contracted with a Medicare Advantage Organization (MAO) may file an appeal.

CMS has established processes by which non-contracted providers may file an appeal.

If, as a non-contracted provider, you believe that Allegian Advantage (HMO) has paid you less than the amount you would have been paid under original Medicare, or your billed service has been denied as included in another service (bundled), or has been paid as a lesser service, known as “downcoding”, click here.

or

If, as a non-contracted provider, you are protesting a zero-dollar payment on your claim, click here.


 

You are a non-contracted provider and you believe that Allegian Advantage (HMO) has paid you less than the amount you would have received under original Medicare, or your billed service denied as included in another service (bundled), or has been paid as a lesser service, known as “downcoding.”

You have the right to file a payment dispute with Allegian Advantage (HMO). Please file that dispute in writing to:

Allegian Advantage
Grievances and Appeals Department
7878 N. 16th Street, Ste. 105
Phoenix, AZ 85020-4443

If timeliness of dispute filing is an issue, you may also fax your dispute to (602) 674-6673.

Please enclose a written narrative explaining the nature of the dispute, the expected outcome, a copy of the claim and any pertinent supporting documentation.

Remember that a payment dispute is considered timely if received by the Plan within 120 days of the date on the remittance advice when your claim was denied. Failure to timely request a payment dispute within 60 days of the last adverse action is deemed a waiver to all rights to further administrative review.

This time frame is set by The Centers for Medicare and Medicaid Services (CMS) and more information can be found by clicking on the link to the Process Manual below.

We will issue an acknowledgement letter within five (5) days of receiving a payment dispute, and a decision letter within thirty (30) days of receipt. If we deny your appeal, your next step is to forward the appeal to C2C Solutions, the Independent Review Entity (IRE) contracted by CMS to ensure our decisions are correct. You are responsible for forwarding the appeal to C2C within 180 days of the date of the Plan’s decision letter. Choose one of the following methods:

  1. Email. If the submission and associated documents do not contain any personally identifiable health information (PHI), or all PHI has been redacted, the payment dispute decision request can be submitted to a dedicated email box at PDRC@C2Cinc.com. Otherwise, you may submit payment dispute decision requests (including associated documents such as claims forms that may contain PHI) via the following:
  2. Fax to: (904) 224-2710
  3. Mail to:
    C2C Solutions, Inc.
    Payment Dispute Resolution Contractor
    P.O. Box 44017
    Jacksonville, Florida 32231-4017

Please click here to review the C2C’s Payment Dispute Resolution Contractor (PDRC) Process Manual.

The C2C will issue a Payment Dispute Decision (PDD) within sixty (60) days of receipt of your request. The C2C decision is final. You may request a debrief from the C2C within 14 days of their decision if you require more information about their decision. If the C2C overturns the Plan’s denial, we will adjudicate the claim for payment within 30 days of the overturn date.


 

You are a non-contracted provider, and are protesting a zero-dollar payment on your claim.

You have the right to file a reconsideration request (appeal) with Allegian Advantage (HMO). Please file that request in writing to:

Allegian Advantage
Grievances and Appeals Department
7878 N. 16th Street, Ste. 105
Phoenix, AZ 85020-4443

If timeliness of dispute filing is an issue, you may also fax your dispute to (602) 674-6673.

Please enclose a written narrative explaining the nature of your request, the expected outcome, a copy of the claim and any pertinent supporting documentation.

Remember that a reconsideration request is considered timely if received by the Plan within 60 days of the date on the remittance advice when your claim was denied. This time frame is set in Federal Regulation. Click here to reference Code of Federal Regulations Title 42 - 422.582(b). Failure to timely request a reconsideration within 60 days of the last adverse action is deemed a waiver to all rights to further administrative review.

CMS also requires that a non-contracted provider sign a Waiver of Liability form when requesting a reconsideration. A copy of that form can be obtained by clicking here. Failure to submit the Waiver of Liability will result in dismissal of your request. You will receive a letter from the IRE (see below) confirming dismissal.

We will issue an acknowledgement letter within five (5) days of receiving a reconsideration request (appeal) that includes the Waiver of Liability and a decision letter within sixty (60) days of receipt. If we deny your request, we will forward your file to Maximus Federal Services, the Independent Review Entity (IRE) hired by CMS to ensure our decisions are correct.

The IRE issues an acknowledgement letter within two (2) days of receipt of the file, and a decision letter within sixty (60) days. If the IRE overturns our denial, your claim will be reprocessed for payment according to their instructions within 30 days. If the IRE upholds our denial, you may have further appeal rights through Maximus Federal Services. For more information, click here to access the Maximus Reconsideration Process Manual.

H8554_011-2017 Approved (Updated 11/07/16)

We're sorry. The zip code you entered is not part of our service area.
Please enter a valid zip code.