Forms & Documents

Appeals and Provider Claim Dispute

Medicare Appeals

Provider Appeal Form - Electronic Submission

Provider Appeal Form - Fillable PDF

Waiver of Liability Form

Appointment of Representative Form (CMS - 1696) (For Medicare Appeals, Grievances, and Coverage Requests only)

Appeals Types

An Appeal may be filed for any of the following reasons:

Standard

1. Part C Pre-Service Appeal – appeals of an adverse decision for pre-authorization of a service
2. Part C Payment Appeal – appeal of an adverse decision of a claim
3. Part D Appeal – appeal of adverse decision regarding a part D medication

Who Can Appeal?

An Appeal may be filed by the following:

Part D Appeal

Appeal of adverse decision regarding a Part D medication -- Prescriber - MD, DO, NP, PA can file over the phone, in writing or by fax

Part C Pre-Service Appeal

Appeal of an adverse decision for pre-authorization of a service -- Physician - can file over the phone, in writing or by fax

Part C Payment Appeal

Appeal of an adverse decision of a claim must be received in writing

1. 1. Any Provider can appeal for a member with a signed Appointment of Representative (AOR-1696).
   2. Non-contracted providers may appeal on their own behalf if they sign a Waiver of Liability (WOL). Or on behalf of a member with a signed AOR (CMS 1696) When a non-contracted provider signs a Waiver of Liability, and the adverse decision is upheld, they agree not to bill the member for the services in question.

Providers can use the forms above, otherwise request for Appeal need to include the following:

1. Member name
2. Address
3. Member number
4. Reasons for appealing
5. Any evidence included for review, such as medical records, doctor’s letters, or other information that support why the service or item is necessary.

Provider Claim Disputes

Must be submitted in writing using forms below

Provider Claim Dispute Form - Electronic Submission

Provider Claim Dispute Form - Downloadable PDF (Print and Fax)

Payment Dispute – Providers disputing the manner in which a claim was paid

1. 1. Can be submitted by a Par (contracted) or Non-Par (non-contracted) provider
   2. Request payment must be submitted in writing.
   3. Request must include supporting documentation for all items dispute.

Par Provider Reconsideration – Dispute of a claim or claim line denial

1. 1. Par Provider Reconsiderations are not a CMS requirement, but instead are a service provided by ATRIO to contracted providers.
   2. Request for par provider reconsideration must be submitted in writing.
   3. Request must include supporting documentation for all items in dispute - Any evidence included for review, such as medical records, doctor’s letters, or other information that support why the service or item is necessary.