Non-Contracting Provider Payment Disputes
Provider Type
- Participating Physician Groups (PPG)
Dispute a participating physician group’s (PPG’s) written determination following its dispute resolution process when the dispute involves an underpayment of the Medicare Fee Schedule within 180 days from the notice issued by the PPG.
Participating physician groups (PPGs) who are delegated for claims payment also process claim payment disputes submitted by non-contracting providers. A non-contracting provider may submit a claims payment dispute if they believe the payment amount they received for a service provided to a member is less than the amount paid by Original Medicare.
Delegated PPGs must instruct non-contracting providers who disagree with the PPG's initial payment review determination decision to submit second-level payment dispute requests in writing to Provider Appeals.
Delegated PPGs must use the uphold (PDF) and overturn (PDF) template letters to advise non-contracting providers to contact the plan if they disagree with the PPG's decision.