Appeal Rights

Contracted Providers:

In accordance with the Medicare managed care regulations, contracted providers DO NOT have Medicare appeal rights for payment disputes. However, Advantage by Superior HealthPlan HMO SNP (Superior) has a review process to address any contracted provider claim issues. Requests for contracted provider claims reviews must be received by Superior within 120 days from the date of this EOP. A copy of this EOP and supporting justification or documentation (such as medical records) must be submitted with the review request

Non-Contracted Providers:

In accordance with the Medicare managed care regulations non-contracted providers have Medicare appeal rights. Medicare appeal rights apply to any claim for which Superior has denied payment. All requests for payment appeals must include a completed and signed “Waiver of Liability” (WOL) statement. Superior cannot begin the appeals process until a completed and signed WOL is received. Requests for appeals that do not include a WOL will be forwarded to Centers for Medicare and Medicaid Services (CMS) contracted Independent Review Entity (IRE) for dismissal in accordance with Medicare rules. Requests for payment appeals must be filed within 60 calendar days of this EOP. A copy of this EOP and any other supporting documentation (such as medical records when applicable) must be submitted with the appeal request. Superior must make a decision regarding the appeal within 60 calendar days from the date the appeal request was received.

Waiver of Liability Form (WOL): Waiver of Liability Statement

Requests sent to the wrong address will be returned to the submitter. Review Requests should be submitted to the following address:

Advantage by Superior HealthPlan
Corrections, Reconsiderations, or Appeals
P.O. Box 4000
Farmington, MO 63640-4000

If Superior upholds the initial payment denial following review of the appeal or does not make a decision within 60 calendar days from the date the appeal request was received, Superior is required to submit the appeal request for review by the IRE. The IRE will review the appeal and notify the provider in writing of the decision. If Superior upholds the original claim denial, non-contracted providers have the right for the appeal to be reviewed by the CMS contracted IRE.

Payment Dispute Rights

Contracted Providers:

Refer to the Contracted Providers section under the Appeal Rights heading.

Non-Contracted

Providers: In accordance with Medicare managed care regulations, non-contracted providers have Medicare payment dispute rights. Medicare payment dispute rights apply to any claim for which the provider contends the amount paid by Superior for a covered service is less than the amount that would have been paid by Original Medicare. Medicare payment dispute rights also apply to any claim for which there is a disagreement between the non-contracted provider and Superior regarding the Superior decision to pay for a different service than the billed service (often referred to as down-coding of claims). Requests for payment disputes must be filed within 120 calendar days of this EOP. Superior must make a decision regarding the payment dispute within 30 calendar days from the date the payment dispute was received.

Requests sent to the wrong address will be returned to the submitter. Payment disputes should be submitted to the following address:

Advantage by Superior HealthPlan
Corrections, Reconsiderations, or Appeals
P.O. Box 4000
Farmington, MO 63640-4000

Once Superior has made an internal decision regarding a payment dispute filed by a non-contracted provider, the provider has the right to request an independent review by CMS’ Payment Dispute Resolution Contractor, C2C Solutions, Inc. (C2C). Requests for an independent review by C2C must be submitted within 180 days of receiving notice of the Superior decision. If Superior fails to make a decision regarding a payment dispute within 30 calendar days, the provider may request a Payment Dispute Decision (PDD) from C2C by providing evidence of the payment dispute filed with Superior. C2C will make a decision within 60 days after receiving the provider’s valid and complete request for a PDD. FCSO will notify the provider in writing of the PDD.

Requests for review of a payment dispute by CMS’s payment dispute contractor (C2C) may be submitted as follows:

Mail: C2C Solutions, Inc.
Payment Dispute Resolution Contractor
PO Box 44017
Jacksonville, FL 32231-4017
Fax: (904) 361-0551
E-Mail: PDRC@C2C.com

Note: E-mail may only be used if the submission and all associated documents do not contain any personally identifiable health information (PHI) or PHI had been redacted.

Providers with questions may call C2C at (904) 791-6430.

Payment disputes are subject to CMS review as Medicare Advantage organizations such as Superior are required to pay non-contracted providers the same amount the provider would have received had the provider billed Original Medicare.

The non-contracted provider payment dispute process cannot be used to challenge payment denials by Superior that result in zero payment being made. Payment denials may be appealed as described in the Non-Contracted Provider Appeal Rights section.

NOTE: ADDITIONAL INFORMATION ABOUT THE APPEALS AND PAYMENT DISPUTE PROCESSES CAN BE PROVIDED BY CALLING PROVIDER SERVICES at 1-877-391-5921.