Providence Medicare Advantage Plans non-contract provider appeal rights

What if I don't agree with this decision?

You have the right to appeal the denial of payment made by Providence Medicare Advantage Plans by initiating the Medicare Managed Care Beneficiary Appeals Process. You must submit your request for payment appeal to Providence Medicare Advantage Plans no later than 60 calendar days from the date of the Explanation of Payment (EOP). If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Who may file an appeal?

This process is applicable to you if:

  • You do not have a contract with Providence Medicare Advantage Plans (i.e. you are a non-contract provider) and;
  • Providence Medicare Advantage Plans denied or partially denied a claim for services you provided to a Providence Medicare Advantage Plans member.

How do I file an appeal?

Your request for an appeal must be submitted in writing and must be signed by the initiator. Send your written request for an appeal to:

Providence Medicare Advantage Plans
Attn: Appeals and Grievance Department
P.O. Box 4158
Portland, OR 97208-4158

Or fax your written request to:

1-800-396-4778 or 503-574-8757

What do I include with my appeal?

Please provide us with all appropriate documentation to support your payment appeal such as a copy of the original claim, remittance notification showing the denial and any clinical records and other supporting documentation. You are also required to provide a completed and signed Provider Waiver of Liability (WOL) form (PDF). The completed Provider WOL is required to process your request.

What happens next?

We will process your reconsideration request and respond within 60 days. If we find in your favor, payment will be made at the applicable Medicare rate directly to you. If we do not find fully in your favor, your case file will be forwarded to MAXIMUS Federal Services, Inc. MAXIMUS Federal Service Inc. is an independent review entity (IRE) contracted with the Centers for Medicare and Medicaid Services to review and resolve coverage disputes. You will receive written notification of the decision directly from the IRE- MAXIMUS Federal Service, Inc. If the decision is not in your favor, you will be provided with information regarding additional appeal rights that are available to you.

If you did not include a Provider WOL form, we will notify you in writing. If the Provider WOL is not received within 60 calendar days of Providence Medicare Advantage Plans receipt of your appeal request, your request for appeal will be dismissed. You will receive written notification of the dismissal directly from Providence Medicare Advantage Plans’ Appeals and Grievances Department.

Contact information

If you need information or help, call us at 1-800-603-2340 (TTY: 711).