Provider Payment Dispute Resolution for Non-Contracted Providers

Medicare Advantage organizations, Cost plans, and PACE organizations are required to reimburse non-contract providers for Part A and Part B services provided to Medicare beneficiaries with an amount that is no less than the amount that would be paid under original Medicare. Non-contract providers are required to accept as payment, in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare. Plans should refer to the MA Payment Guide for Out of Network Payments in situations where they are required to pay at least the Medicare rate to out of network providers. A link to the guide can be found below.

In addition, CMS expects all MAOs and payers to act promptly to resolve payment disputes with non-contract providers and to ensure that payments are made in accordance with the law. CMS Account Managers have been instructed to closely monitor MAOs’ actions in this regard and will take compliance actions as necessary.