Instructions for Payment Dispute Decision (PDD) Request Form
Section 1 - “Provider/Supplier Contact Information”
Complete this section with the contact information for the rendering provider/supplier. This should be the address where the provider wishes to receive correspondence from the Payment Dispute Resolution Contractor (PDRC). If a provider is part of a group, the individual provider’s name must be listed first. A group name may also be included on the same line, for mailing purposes. Since the PDRC communicates with providers/suppliers via multiple means, a valid telephone number and email address should be provided, if available. However, the lack of this information would not constitute an incomplete form or cause dismissal of the request.
Section 2 - “Pricing Information”
Information in this section is essential for proper pricing of a claim. Please note that not all sections will apply to all providers/suppliers. The appellant should fill out the sections that apply to the claims at issue.
1. NPI number and CCN/ OSCAR number - The NPI number is the National Provider Identification number that Medicare has assigned to individual providers/suppliers. The CCN (CMS Certification Number) or the OSCAR (On-line Survey Certification and Reporting) number are also known as the institution certification number. This number is essential for institutional providers for correct pricing of a claim.
2. ZIP Code where services were rendered – Required for proper pricing of the claim.
3. Physician Specialty should include the specific specialty name and number.
4. Medicare Advantage Organization (MAO) name / Plan name & number - the name of the MAO along with the specific plan name and number to which the claim was submitted. A MAO may have its own specific Terms & Conditions, with some varying from specific plan to plan within the MAO. Therefore, both the MAO name and the Plan name/number are required.
5. Indicate whether the provider is deemed or non-contracted. For PFFS plans, a non-contracted provider would be one who provided emergency services to a MAO plan member without first reading and agreeing to the MAO Plan’s Terms & Conditions. For all other MAO plans, a provider is considered non-contracted when there is not a signed contract/agreement between the provider and the specific MAO plan (HMO, PPO, etc). For example, a provider may be contracted under a MAO’s HMO plan, but be considered non-contracted for services rendered to a PPO plan member.
Section 3 - “Reason for Payment Dispute”
This section should be utilized to document the specific reasons for the appeal. Some issues require a more detailed explanation. In those cases a separate explanation sheet may be attached to this form.
Section 4 - “Required Information”
1. Submit a copy of the submitted claim form(s) with the specific line items identified. This can be a printed copy of an electronic claim or a hardcopy claim form (UB-04 or 1500).
2. Correspondence of the MAO Plan’s original notice of claim decision to the provider, including the allowed amount, reductions, deductibles, and net paid amount.
3. Correspondence of the MAO Plan’s second level determination result of the payment dispute. This may take different forms from MAO Plan to MAO Plan, but all should show the claims at issue, the amount allowed, and any changes in the payment amount secondary to the decision.
4. A provider should submit specific documentation to support the payment it believes is correct. This may include interim rate letters and/or documentation reflecting payment from Original Medicare for similar or identical services. For PFFS plans, a copy of the PFFS MAO Plan’s Terms & Conditions relevant to the claims at issue will be required as this will be a primary basis for determining the correct payment amount.
5. If the appellant is someone other than the provider or an employee of the provider/group, the provider must give written and signed authorization to the specific person (not a group or organization) that is making the appeal.
Section 5 - “Requester’s Information”
This section should be filled out if someone other than the provider/supplier is completing the form. This form should also be filled out if the provider requires the PDRC decision to go to a different address than listed in the provider section, such as a physician group billing office.
Section 6 - “Requester’s Signature”
All requests must be signed and dated in order to be valid. If the request is being submitted via email, the checkbox under “For electronic submission…” may be checked in place of a written signature. However, the appellants name and date must be entered on the Signature/Date line.
Once completed, the form and the other required documentation may be submitted via mail, email, or fax. The PDRC will review the documentation and take one of two actions: 1) acknowledge (via mail) the request as a new request or 2) contact the appellant if there is incomplete/missing information. For situations of missing/incomplete information, the appellant is given a reasonable amount of time (usually 14 days) to submit the missing/incomplete documentation.
Choose one of the methods below to submit your request for decision:
1. Email. If the submission and associated documents do not contain any personally identifiable health information (PHI), or all PHI has been redacted, the payment dispute decision request can be submitted to a dedicated email box at PDRC@FCSO.com. Otherwise, you may submit payment dispute decision requests (including associated documents such as claims forms that may contain PHI) via the following:
2. Fax to: (904) 361-0551
Questions, general information, and hard copy additional correspondence associated with a dispute, other than information submitted with a original request, request may be mailed to: