Process for Resolving Provider Payment Disputes through the

130.2 - Process for Resolving Provider Payment Disputes through the Payment Dispute Resolution Contractor (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) After completing the PFFS plan’s provider payment dispute resolution process, if a deemed provider still believes that the plan has reached an incorrect decision regarding payment on a claim, the provider may file an additional request for review with an independent review organization contracted by CMS. To file this additional request for review of a payment dispute with the independent review organization, the provider may contact the Payment Dispute Resolution Contractor (PDRC) directly. Information on filing a dispute with the PDRC is available on the CMS website at https://www.cms.gov/HealthPlansGenInfo/18_ProviderPaymentDisputeResolution.asp. The deemed provider must first complete the PFFS plan’s provider payment dispute resolution process before requesting a review by the independent review organization. Both deemed and non-contracting providers furnishing services to PFFS members may file payment disputes with the PDRC. The provider payment dispute process cannot be used to challenge payment denials by organizations that result in zero payment being made to the non-contracted provider. Instead, these matters must be processed as appeals under 42 CFR Subpart M. In addition, the payment dispute process may not be used to resolve payment disputes between contracted network providers and organizations covered by this process. However, in cases where the plan makes a payment but the provider disputes the amount of the payment the provider may utilize the provider payment dispute process.