Process for Resolving Provider Payment Disputes through the

130.1 – Process for Resolving Provider Payment Disputes through the PFFS Plan (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) Under its contract with CMS, PFFS plans are required to have a process in place to resolve provider payment disputes. A PFFS plan is required to ensure that deemed providers are being paid according to its terms and conditions of payment. If a deemed provider believes that the payment amount the provider received from the PFFS plan is less than the amount indicated in the plan’s terms and conditions of payment, then the provider has the right to dispute the payment amount following the plan’s provider payment dispute resolution process. The provider payment dispute resolution process must be explained in the PFFS plan’s terms and conditions of payment. In its description of the provider payment dispute resolution process, the PFFS plan must describe how a provider can file a dispute with the plan and the appropriate documentation that the provider should submit to the plan to demonstrate that the plan paid the provider less than required under the PFFS plan’s terms and conditions of payment. The following guidelines identify some optimal features of a provider payment dispute resolution process, which CMS encourages all PFFS plans to implement. PFFS plans that follow the model features of the provider payment dispute process will meet CMS’ requirements. CMS considers an effective provider payment dispute process a critical part of a PFFS plan since it will encourage provider participation in the plan. Model Features of a Provider Payment Dispute Process: 1. The PFFS plan has a system for receiving provider payment disputes (e.g., dedicated phone line, e-mail address) and establishes a specific and reasonable timeline for resolution/adjudication of disputes. (CMS recommends 30 days from the time the provider payment dispute is first received by the plan.) 2. The PFFS plan maintains a record of provider payment disputes and documents its final decisions regarding provider payment disputes. The PFFS plan has the capacity to report this information to CMS upon request - including documentation of any corrective actions taken to prevent future payment errors. 3. If the PFFS plan finds for the provider (i.e., it agrees that it initially underpaid the provider), in addition to paying the provider the additional amount due in a timely manner, the plan should correct its payment system going forward, and identify similar claims for that contract year to ensure that it has paid them correctly. 4. The PFFS plan informs the provider in writing of its decision in cases where a provider payment dispute is denied by the plan. CMS has provided language in its model terms and conditions of payment to describe a PFFS plan’s provider payment dispute resolution process. Refer to section 50.2 of this chapter. As discussed in section 110 of this chapter, PFFS plans must pay clean claims from deemed providers within 30 days. When reviewing a provider payment dispute process, CMS will review the PFFS plan’s terms and conditions of payment and the rate at which it rejects provider claims from the clean-claim process. Specifically, the plan’s terms and conditions of payment must furnish clear instructions telling providers how to bill the plan for services furnished to its members. CMS will pay particular attention to PFFS plans that reject a large percentage of claims because they are not clean (i.e., claims not paid because they were not billed according to plan instructions). CMS will determine what constitutes a large number of rejected claims based on comparisons with the average rejection rate of other PFFS plans. CMS will also review the terms and conditions of payment to ensure that it clearly informs providers how they can appeal to the plan if the provider believes the amount paid by the plan is less than what is described in its terms and conditions of payment. In its review, CMS will pay particular attention to how the plan documents its process and if it appropriately responds to provider appeals in a timely manner.