ODS Advantage plan claims and appeals
Noncontracted provider appeals
Provider payment disputes subject to CMS’ independent review process include any decisions where a noncontracted provider contends that the amount paid by the organization for a covered service is less than the amount that would have been paid under Original Medicare.
Instructions for submitting your written appeal
Once an organization makes its internal decision about an initial payment dispute filed by a noncontracted provider, the provider has the right to request an independent decision from CMS’ Payment Dispute Resolution Contractor, First Coast Service Options Inc. (FCSO). In addition, if the organization fails to make a decision in response to a noncontracted provider dispute request within 30 days from the date the dispute request was received by the organization, the provider may request a Payment Dispute Decision (PDD) without having received an initial internal dispute decision by providing evidence to FCSO of the dispute it filed with the organization. Such disputes are subject to CMS review because organizations are required to pay noncontracted providers the same amount as they would have received had they billed Original Medicare.
Filing a request for an independent payment dispute resolution
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