Medicare Advantage Non-Contracted Provider Appeals: What You Need to Know

If you are a Medicare Advantage plan member and have received care from a provider who is not contracted with your plan, you may find yourself with a surprise bill. But did you know that you may have the right to appeal this bill and potentially have it covered by your plan? Here`s what you need to know about non-contracted provider appeals.

What is a Non-Contracted Provider?

A non-contracted provider is simply a healthcare provider who does not have a contract with your Medicare Advantage plan. Your plan has a network of contracted providers who have agreed to accept the plan`s payment rates for their services. If you visit a provider who is not in your plan`s network, you may have to pay more out-of-pocket or the service may not be covered at all.

Why Would I Visit a Non-Contracted Provider?

There are a few reasons why you may end up seeing a non-contracted provider. One possibility is that you may need emergency care and be taken to the nearest hospital, which may not be in your plan`s network. Another possibility is that you may prefer a certain provider who is not in your plan`s network, or that you may not have known that the provider was non-contracted when you received care.

What Can I Do if I Receive a Surprise Bill?

If you receive a bill from a non-contracted provider and are not sure if it should be covered by your Medicare Advantage plan, you can file an appeal. Here are the steps to take:

1. Contact Your Plan: Call your plan`s customer service number to let them know about the bill you received. Ask if the service should have been covered under your plan and what your options are for filing an appeal.

2. Gather Information: You will need to provide information about the service you received, the provider, and the bill you received. Make sure you have all of this information handy before you start the appeals process.

3. File an Appeal: Your plan should have an appeals process in place for non-contracted provider claims. Follow the instructions provided by your plan to file an appeal. You may need to provide additional documentation or information to support your appeal.

4. Wait for a Decision: Your plan will review your appeal and make a decision about whether or not to cover the service. This decision may take several weeks or more, so be patient.

What if My Appeal is Denied?

If your appeal is denied, you still have options. You can file a complaint with your plan or with Medicare. You can also contact your state`s insurance department for assistance.

In Conclusion

If you receive a surprise bill from a non-contracted provider, don`t panic. You have options for appealing the bill and potentially having it covered by your Medicare Advantage plan. Make sure to gather all of the necessary information and follow your plan`s appeals process to give yourself the best chance of success.