Non-Contracting Provider Payment Disputes

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, or when the provider disagrees with the PPG's decision to pay for a different service or level than billed. Some other reasons for payment disputes are:

• Bundling issues
• Diagnosis related group (DRG) payments
• Downcoding

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.