Appeals post service: Non-contracted provider

If you are a non-contracted provider making a post-service Medicare appeal, follow our standard payment reconsideration process outlined below.

  1. Submit your appeal within 60 calendar days from the date of the Remittance Advice.  Include  a Waiver of Liability and send by mail or fax:

    Priority Health Medicare Appeals
    1231 E. Beltline Ave NE
    MS1150
    Grand Rapids, MI  49525
    Fax Number 616.975.8827
  2. Priority Health Medicare will review your appeal and notify you in writing of our decision within 60 calendar days.
  3. If Priority Health Medicare renders a partial or fully adverse decision, we automatically send your appeal to MAXIMUS Federal Services. This is Medicare’s Independent Review Entity (IRE).  They will review the appeal within 60 calendar days to make sure the correct decision was made.  You will receive a correspondence by mail regarding their decision.
  4. If the IRE renders a favorable decision for you, Priority Health Medicare must effectuate and comply with the IRE’s decision.  A new Remittance Advice will be sent to reflect the IRE’s decision.

For more information on Part C requirements for Provider Claim Appeals see section 50.1.1. 

Frequently asked questions

What is the non-contracted provider appeal process for Priority Health Medicare?

A non-contracted provider can file a post service Medicare appeal for a denied claim with a Waiver of Liability, stating the non-contracted provider will not bill the enrollee regardless of the outcome of the appeal.

How do I submit a non-contracted provider post service Medicare appeal?

CMS does not require a specific form for non-contracted providers to submit a Medicare appeal. Non-contracted providers must include a Waiver of Liability and any information supporting the appeal. You can send by mail or fax.

Priority Health Medicare Appeals
1231 E. Beltline Ave NE
MS1150
Grand Rapids, MI  49525

The appeal can be faxed to 616.975.8827

What is MAXIMUS Federal Services?

MAXIMUS Federal Services is an Independent Review Entity (IRE) Medicare uses to review cases to make sure the right decision was made.  If Priority Health Medicare renders a partial or fully adverse decision, the appeal is automatically sent to the IRE.

What if a Waiver of Liability is not submitted?

Priority Health Medicare will make reasonable attempts to obtain the Waiver of Liability (WOL) within the appeal timeframe.  If Priority Health Medicare does not receive a WOL, the case will be dismissed as indicated in Section 50.9 of CMS' Parts C&D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance section.

What is the timeframe to submit a non-contracted provider Medicare appeal?

Non-contacted providers have 60 calendar days from the date of the Remittance Advice (RA) to submit a post service Medicare appeal.  A Waiver of Liability (WOL) must be submitted with the appeal.  The adjudication timeframe begins when the WOL is received by the plan.