Summary of PDRC Process
Summary of the Independent Review of Medicare Advantage Provider Payment Disputes Program for Non-Contracted and Deemed Providers

Effective January 1, 2009, CMS delegated the adjudication of PFFS Provider Payment disputes to a Payment Dispute Resolution Contractor, First Coast Service Options, Inc. (FCSO). Prior to January 1, 2009, these requests were being adjudicated by Central and Regional Office staff. Beginning January 1, 2009 after a MA PFFS Plan informs a provider in writing that its payment dispute has been denied through the MAO’s provider payment dispute process, a provider or supplier that disagrees with the pricing decision has the right to request the decision be reviewed by an independent review entity under contract with CMS. Effective January 1, 2010, CMS expanded this payment dispute resolution process to include payment disputes between non-contacted providers and any MA Plan.

1. Decisions Subject to the Payment Dispute Process: Provider payment disputes include any decisions where there is a dispute about the payment amount made by a MAO Plan to a non-contracted provider that is less than the rates of Original Medicare or to a deemed provider (PFFS only) that is less than the rates specified in the plan’s terms and conditions if greater than Original Medicare’s rates.

2. Decisions Not Subject to the Provider Payment Dispute Process:

  • National Coverage Determinations (NCDs)
  • Services denied for coverage issues such as Local Coverage Determinations (LCDs)
  • Medical necessity determinations are not subject to the independent review process and should be sent to the appropriate Qualified Independent Contractor (QIC) for processing
  • Disputes between a contracted network provider and the MA Plan are also not reviewed by the PDRC or CMS

    • 3. Filing a Request for Independent Review (Payment Dispute Decision): A request for an Independent Payment Dispute Decision (PDD) must be submitted to FCSO in writing within 180 days of written notice from the MA Plan. The request must be in writing and should be made on a standard PDD form available at the FCSO’s PDRC webpage. All requests must be received within 180 days of a written decision by the MA plan. A written request that is not made on the standard PDD form will be accepted if it contains all the required elements, as follows:

  • Provider or Supplier Contact information including name and address.
  • Pricing Information, including NPI number (and CCN / OSCAR number for institutional providers), ZIP Code where services were rendered, Physician Specialty, the name of the MAO that made the redetermination including the specific plan name, and whether the provider/supplier is deemed or non-contracted.
  • Reason for dispute; a description of the specific issue.
  • Copy of the provider’s submitted claim with disputed portion identified.
  • Copy of the MA plan’s original pricing determination.
  • Copy of the MA plan’s redetermination (dispute) pricing decision.
  • Copy of the relevant portion of Terms and Conditions or contract and any supporting documentation and correspondence that support your position that the plan’s reimbursement is not correct (this may include interim rate letters and/or documentation reflecting payment from Original Medicare on similar or identical services.)
  • Appointment of Provider or Supplier Representative Authorization Statement, if applicable.
  • The name and signature of the party or the representative of the party.

    • 4. Obtaining the MAO documentation: Providers or suppliers that have exhausted the dispute resolution process of the MA organization and wish to escalate must file requests for a PDD directly with the Payment Dispute Resolution Contractor (PDRC). Once a party requests a PDD, the PDRC may request documentation from the MAO that processed the redetermination. When the MAO receives the PDRC’s request for the case file, the MAO must send the file within seven calendar days so that the PDRC receives it on or before the eighth day. MAOs that do not respond timely to PDRC requests will be considered out of compliance with their CMS contract and subject to compliance processes.

    5. Time Frame for Making a Payment Dispute Decision (PDD): The Payment Dispute Resolution Contractor (PDRC) will issue a decision within 60 days after receiving a provider payment dispute appeal unless granted an exception by the PDRC. The PDRC will notify all parties of its PDD or notify all parties that it has dismissed the request for a PDD.

    6. Decision Letters: The Payment Dispute Decision letter will include the facts of the appeal, arguments made for and against additional reimbursement, the adjudicator’s decision, and the adjudicator’s rationale, and notification to the parties of their right to request a debrief.

    7. Notification of Parties: When the PDRC renders a decision on a case it notifies all parties of its decision. The PDRC considers the case closed when it notifies all parties of the decision. However, both parties have the right to request a debrief.

    8. Compilation of Decisions and Lessons Learned: The PDRC will maintain a log of all decisions rendered and will work collaboratively with CMS to provide information back to MA organization on the cases raised and the decisions rendered. MA organizations will have the opportunity to learn from these experiences, and amend their practices accordingly.