FIDA Non-Participating Provider Appeal Rights and Process Summary

An out–of–network or FIDA Non–Participating Provider who has provided services to a FIDA Participant and has been denied payment may appeal using the Integrated Appeal Process outlined in the Three–Way Contract for the FIDA Program. This document outlines the rules and procedures that apply when a Non–Participating Provider is appealing on his/her own behalf. Procedures for providers appealing on behalf of a participant are unchanged.

Coverage/Payment Decision and ICDN:

Upon reaching an adverse coverage or payment decision, FIDA Plans must send FIDA Non–Participating Providers 1) a copy of the ICDN sent to the Participant, 2) a Template Waiver of Liability form to be submitted with the Non–Participating Provider´s appeal request, and 3) a copy of this FIDA Non–Participating Provider Appeal Rights and Process Summary.

1st Level Appeal – Plan Appeal Review:

When a Non–Participating Provider receives a denial or partial denial of a claim, the Non–Participating Provider may file a 1st Level Appeal (with the FIDA Plan).

This must be requested verbally or in writing within sixty (60) calendar days of postmark date of notice received by the Non–Participating Provider. The Appeal must be accompanied by a signed statement that says: "I hereby waive any right to collect payment from [name of Participant], the Participant, for the aforementioned services for which payment has been denied by the above–referenced health plan. I understand that the signing of this waiver does not negate my right to request further appeal under Medicare rules." A template waiver of liability form has been provided to FIDA Plans to send to Non–Participating Providers with the ICDN and this summary.

The FIDA Plan must send a written acknowledgement of the Appeal to the Non–Participating Provider within fifteen (15) calendar days of receipt. If a decision is reached before the written acknowledgement is sent, the FIDA Plan will not send the written acknowledgement.

The FIDA Plan conducts a paper review and must complete this no later than sixty (60) calendar days from the date of the receipt of the Appeal for reimbursement requests and no later than thirty (30) calendar days from the date of the receipt of the Appeal for all other Appeals.

An extension of up to 14 days may be requested by a Provider (written or oral). The FIDA Plan may also initiate an extension of up to 14 days if it can justify need for additional information and if the extension is in the Non–Participating Provider´s interest.

The FIDA Plan must mail written notice of a decision to the Non–Participating Provider. The written notification of Appeal decision must include the results and the date of the Appeal decision. For decisions not wholly in the Non–Participating Provider´s favor, the notification must inform the Non–Participating Provider that such adverse decision will be automatically forwarded to the Integrated Administrative Hearing Office at OTDA. The notification must inform the Non–Participating Provider of the process and time frame for the hearing before IAHO.

Automatic Administrative Hearing. Any wholly or partially adverse decision by the FIDA Plan is automatically forwarded along with the Appeal review record to the IAHO. The FIDA Plan must auto–forward an adverse decision within 2 business days of it being reached. The FIDA Plan should also continue to forward cases to the IRE in accordance with the integrated appeals quality assurance process.

The FIDA Plan must notify the Non-Participating Provider that an Appeal was sent to IAHO. Once the IAHO receives the notice from the FIDA Plan, IAHO will contact the Non–Participating Provider regarding the hearing date. The Non–Participating Provider should contact IAHO in the event that he/she doesn´t hear from IAHO to schedule the hearing within 10 calendar days. Note that the provider´s statement waiving participant liability must be included in file forwarded to IAHO.

The FIDA Plan must send an Acknowledgement of Automatic Administrative Hearing within fourteen (14) calendar days of forwarding the administrative record with a copy to IAHO.

2nd Level – Integrated Administrative Hearing:

The IAHO shall provide the Non–Participating Provider and the FIDA Plan with a Notice of Administrative Hearing at least ten (10) calendar days in advance of the hearing date.

The Non–Participating Provider and the FIDA Plan must participate in the hearing. IAHO will verify that the Non–Participating Provider has included a statement waiving participant liability. IAHO will conduct a phone hearing and render a decision within ninety (90) calendar days from the date the Non–Participating Provider requests an appeal with the FIDA Plan.

IAHO will issue a written decision that explains in plain language the rationale for the decision and specifies the next steps in the Appeal process. The FIDA Plan is bound by the decision of the IAHO and may not seek further review. The FIDA Plan must implement the IAHO decision immediately (within no more than one (1) Business Day).

3rd Level – Medicare Appeals Council:

If a Non–Participating Provider disagrees with the IAHO´s decision, the Non–Participating Provider may appeal that decision further to the Medicare Appeals Council, which may overturn the IAHO´s decision. The Non–Participating Provider must submit his/her request for Medicare Appeals Council review to the IAHO within sixty (60) calendar days of the date of the adverse decision by the IAHO. The IAHO will forward the Appeal and the record to the Medicare Appeals Council. The Medicare Appeals Council will complete a paper review and will issue a decision within ninety (90) calendar days from the receipt of the appeal request.

4th Level – Federal District Court:

An adverse Medicare Appeals Council decision may be appealed to the Federal District Court, which serves as the fourth level of Appeal.

December 13, 2016