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Non-Contracted Provider (NCP) Appeal Requests or Dispute Resolution Process for Part C Claims

Non-contracted providers have the right to submit appeals or disputes when they do not agree with Alignment's claim payment decision. Alignment established submission and processing timelines according to the Center for Medicare & Medicaid Services (CMS).

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  • Non-Contracted Provider Appeal Requests or Payment Dispute Requests

    A non-contracted provider (NCP) has the right to appeal or request reconsideration for a Medicare Advantage plan's claim payment determination, and MA plans handle first-level appeals. NCPs may submit an appeal request or a payment dispute request due to the following reasons:

    • Bundling issues and disputed rate of payment (pre-pay bundling, post-pay bundling, and global payment determinations) - e.g., the denial of procedure codes (as mutually exclusive to another paid procedure code) or due to inclusion in a previously paid global surgical package.
    • DRG payment denials - the MA plan initially approves the claim, which is considered a favorable organization determination, then the MA plan later reopens and revises the favorable organization determination to deny the DRG code on the basis that a different DRG code should have been submitted and recoups funds.
    • Downcoding - the MA plan initially approves coverage for inpatient services from a NCP, which is considered a favorable organization determination, then the MA plan later reopens and revises the favorable organization determination (e.g., retrospective review) to determine the enrollee should have received outpatient services.
    • Level of care or rate of payment denials (payment of a reduced fee schedule amount for a course of treatment) - e.g., a provider bills a procedure code for a visit but the MA plan reimburses based on a lower level of care.
    • Local and national coverage determinations
    • Payment denials by payers that result in zero payments
    • Partially approved decisions
    • Medical necessity determinations
    • Failure to submit requested medical records
  • Requirements for Non-Contracted Provider Appeal Request Submission and Processing
    • An appeal request must be submitted in writing within 60 calendar days of the remittance advice date.
    • An appeal request must have a completed and signed Waiver of Liability (WOL), an appeal request without a valid WOL will be dismissed. The appeal request processing deadline is based on when the complete and signed WOL is received.
    • All NCP appeal requests must be submitted to Alignment Health Plan.
    • An appeal request should include the following:
      • Provider's contact information: name, phone number, fax number, mailing address, and email address (if available)
      • Copy of original claim, remittance notification, and notice of denial
      • Item(s) being appealed
      • Provider contract status (if payment/denial was issued by Alignment Health Plan’s delegated entity or IPA)
      • Clinical records and other documentation that supports the provider's argument for reimbursement
    • Alignment Health Plan has 60 calendar days to review and respond after receiving the complete appeal request. If AHP upholds all or part of the initial payment determination, AHP will forward the appeal request to the CMS Independent Review Entity (IRE) for a level 2 appeal.
    • The IRE will review the case and send their level 2 appeal determination to the NCP and the MA plan within 60 calendar days upon receipt of the appeal from the MA plan.
  • Non-Contracted Provider Dispute Resolution

    As a Medicare Advantage plan, Alignment Health Plan reimburses NCPs for authorized and/or covered services with an amount that is no less than the amount that would be paid under original Medicare. NCPs are required to accept as payment in full, meaning the amounts that the provider could collect if the members were enrolled in original Medicare.

  • Requirements for NCP Payment Dispute Request Submission and Processing
    • A payment dispute request must be submitted within 120 calendar days of the remittance advice date in writing.
    • A payment dispute request should include the following:
      • Provider's contact information: name, phone number, fax number, mailing address, and email address (if available)
      • Copy of original claim and remittance notification
      • Item(s) being appealed
    • Alignment Health Plan has 30 calendar days to review and respond after receiving the payment dispute request.
  • Claims processed or paid by Alignment Health Plan’s Delegated Entity or Participating Provider Groups
    • If a provider is not contracted with Alignment Health Plan's participating provider group and disagrees with the provider group's payment decision or denial, an appeal request must be submitted to Alignment within 60 calendar days of the participating provider group's remittance advice. Refer to the requirements in the Non-Contracted Provider Appeal Request Submission and Processing section.
    • If a provider is not contracted with Alignment Health Plan's participating provider group and disagrees with the provider group's first-level provider dispute payment decision, second-level provider dispute requests must be submitted to Alignment within 180 calendar days of the participating provider group's written notice of their Level 1 dispute decision. Refer to the requirements in the Requirements for NCP Payment Dispute Request Submission and Processing section.

Part C Claims Submission and Processing Guidelines

  • Submission Formats

    Alignment Health Plan strongly encourages non-contracted providers (NCPs) to submit claims electronically. Electronic claims submission is at no cost to the provider and helps effectuate the timely disposition of claims in accordance with Centers for Medicare & Medicaid Services (CMS) requirements.

    Alignment applies the appropriate Strategic National Implementation Process (SNIP) edits for all claims received. Providers must bill the appropriate HIPAA-compliant billing codes. When billing codes are updated, the provider is required to use appropriate replacement codes for submitting claims for covered services. Alignment will not reimburse any claims submitted using noncompliant billing codes.

    Benefits of electronic claims submission include faster disposition, improved claims control, and standardized industry format.

  • Electronic Claims

    Non-contracted providers can submit all professional and institutional claims including attachments (such as medical/emergency records, invoices, explanation of benefits from another health insurance or payer, itemized bills, etc.) electronically through Office Ally at no cost to the Provider.

    Our Payer ID with Office Ally is CCHPC.

    To enroll for electronic claim submission, please contact Office Ally:

  • Paper Claims

    Paper claims must be submitted to Alignment Health Plan on current CMS standard forms:

    • Hospital, skilled nursing facility (SNF), home health, inpatient mental health, inpatient psychiatric, and ESRD dialysis claims must be billed on UB-04
    • Physician and all other claims (DME, lab/X-ray, transportation, and ancillary services) except pharmacy, must be billed on CMS-1500
  • Mail Paper Claims to

    Alignment Health Plan
    Attn: Claims Department
    P.O. Box 14012
    Orange, CA 92863-1412

  • Submission Time Frames

    Non-contracted providers must submit claims within 12 months from the date of service. If the claim is filed beyond the timely filing limit, the claim will be denied unless proof of a timely filing or a good cause reason for the late claim submission is shown. A good cause reason may be accepted when a delay is due to the following:

    • Administrative error - incorrect or incomplete information was furnished by official Medicare sources (e.g., carrier, intermediary, CMS) to the provider
    • Unavoidable delay in securing required supporting claim documentation or evidence from one or more third parties despite reasonable efforts by the physician/supplier to secure such documentation or evidence
    • Unusual, unavoidable, or other circumstances beyond the service provider's control which demonstrate that the physician or supplier could not reasonably be expected to have been aware of the need to file timely
    • Destruction or other damage of the physician's or supplier's records unless such destruction or other damage was caused by the physician's or supplier's willful act or negligence.

Claims Processing and Payment

  • Billing for Drug-Related Claims and National Drug Code (NDC) Reporting

    When submitting drug-related claims, each claim line with a drug-related Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code must include the following additional information:

    Required Information

    Other Requirements (If applicable)

    11-digit NDC number on the container from which the medication was administered

    • NDC number must not have spaces or hyphens

    • If the NDC on the prescription label is fewer than 11 digits, it will be necessary to add leading zeros (0)

    • If there is more than one NDC for the HCPCS/CPT code (e.g., compounded drugs, drugs with different strengths), each NDC and the associated information must be submitted as a separate line item

    • If billing multiple lines for the same injectable medication due to different NDC numbers, a modifier 59 is required

    • Professional: Enter on field 24D of the CMS-1500 or Loop 2410 LIN03 segment of the HIPAA 837p electronic form

    • Institutional: Enter on field 43 of the UB-04 or Loop 2410 LIN03 segment of the HIPAA 837i electronic form

    • Due to the implementation of the HIPAA X12 version 5010, only one LIN03 segment is used to report supplemental NDC information along with the HCPCS/CPT code

    Unit price

    This apply to EDI only

    Two-digit unit of measure code

    GM (gram), ML (milliliter), UN (unit)

    Number of NDC units dispensed


  • Claim Reimbursement

    As a Medicare Advantage (MA) plan, Alignment Health Plan reimburses non-contracted providers (NCPs) for authorized and/or covered services with an amount that is no less than the amount that would be paid under original Medicare.

  • Collection of Copayments, Coinsurance and Deductibles

    Non-contracted providers shall be responsible for the collection of copayments, coinsurance, and/or deductibles upon rendering covered services to members. Providers shall not refuse to provide covered services in the event a member is unable to pay the member's copayments, coinsurance, and/or deductibles except as may be otherwise specifically approved in advance by Alignment.

  • Coordination of Benefits - Medicare Secondary Payer and Third-Party Liability

    Medicare Secondary Payer is the term generally used when the member has other primary insurance, such as group health plans and large group health plans. The decision as to who is responsible for paying first on a claim and who pays second is known as the coordination of benefits.

    Alignment does not pay for services to the extent that there is a third party, which is required to be the primary payer. Providers shall bill the primary insurers first. Alignment pays up to the member's cost-sharing amount with Alignment. Alignment may make secondary payments if both of the following apply:

    • The primary carrier payment is less than the gross amount payable by Medicare
    • The provider does not accept and is not obligated to accept the primary carrier's payment as payment in full

    In the case and presence of third-party liability (e.g., workers' compensation, no-fault, and liability insurance), Alignment makes conditional payments if the other insurance does not pay promptly. The conditional payments are subject to recovery when and if the other insurance does make payment.

    All claim payments to providers are subject to retrospective review to determine whether any third-party liability exists and to recovery where such liability is determined to exist. Alignment may use a vendor to conduct a retrospective review on its behalf for third-party liability and recovery purposes.

  • Corrected Claims

    Providers resubmitting claims for corrections must clearly mark the claim as "Corrected Claim/s." Failure to mark the claim appropriately may result in the denial of the claim as a duplicate. Corrected claims must be received within the applicable and timely filing requirements of the original claim.

  • Definition of Clean Claims

    A "clean claim" means a claim that has no defect or impropriety, including lack of any required substantiating information or documentation or any other circumstance requiring special treatment that prevents timely payment of the claim.

    All claims, both electronic and paper, must conform to CMS clean claims requirements and claims billing and submission guidelines, including those set forth in the Medicare Claims Processing Manual and in accordance with prevailing Correct Coding Initiative (CCI) edits.

  • Maximum Out-of-Pocket Limit

    Alignment members under certain benefits plans have limits on their cost-sharing amounts during a benefit year. Once these limits are reached for the benefit year, Alignment will no longer deduct cost-sharing amounts from the provider's payments until the following benefit year or when the Member changes benefits plans.

  • No Balance-Billing

    Under CMS regulations, providers cannot balance-bill the member. Members cannot be billed for covered services beyond their normal cost-sharing amounts (copayment, deductible, or coinsurance). Providers shall not collect payments from members for services unless the member has been advised in writing that such services may not be covered and Alignment confirms such services are not covered.

    If the member is a Duals/Qualified Medicare Beneficiary (QMB) member, this member must not be billed for the cost-sharing amount. QMB’s cost-sharing amount is covered under the member’s Medicaid coverage.

    Reference: Medicare Managed Care Manual. Chapter 4, Section 170.2 Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act (Act) forbid Medicare providers and suppliers from billing QMB or QMB Plus recipients for cost-sharing.

  • Payment Sequestration

    CMS has reinstated the payment sequestration beginning date of service to April 1, 2022. Payment for claims with dates of service or dates of discharge from April 1, 2022 to June 30, 2022 will incur a 1% reduction in Medicare payment and 2% for claims with dates of service or discharge starting July 1, 2022. Alignment has applied these reductions accordingly. Claim payment adjustments are applied to all claims after determining coinsurance, deductible, Merit-based Incentive Payment (MIPS) adjustments, and any applicable Medicare Secondary Payment adjustments. Patients may not be billed for these reductions.

  • Processing Timeframes

    A non-contracted provider's clean claims are paid within 30 calendar days of the earliest receipt date. Claims that require additional information such as medical or clinical records, itemized bills, invoices, or any documents required to make payment determination are paid or denied within 60 calendar days of the earliest receipt date. If the requested information is not received, Alignment Health Plan will process claims based on the information on hand. A claim may be denied if the information on hand is not sufficient to make a determination.

  • Rejected Versus Denied Claims

    Providers must ensure that paper claims submitted to Alignment are clean and accurate. Claims submitted by paper must be legible. Alignment may reject claims that are not processable (i.e., unclean) due to missing or invalid required information. Rejected claims do not have appeals rights. Providers must correct and resubmit claims for further processing or adjudication.

    Alignment will deny a claim determined to be non-payable. Claims considered non-payable include but are not limited to services, medical equipment, or supplies that are identified as non-covered benefits, claims for unauthorized services, or otherwise due to the member’s lack of coverage.

  • Unlisted and Unclassified Codes

    Alignment requires that non-contracted providers submit the appropriate documentation on all claims for services or procedures that are not otherwise specified.

    Alignment may send a request to non-contracted providers for documentation that supports the need to bill for unlisted/unclassified procedure codes. Because unlisted/unclassified procedure codes do not describe a specific procedure or service, it is necessary for the providers to submit supporting documentation when filing the claim (see the table below.) Claims billed with unlisted/unclassified procedure codes without supporting documentation will be subject to denial if the provider fails to provide the supporting documentation.

    Non-contracted providers must submit supporting documentation, along with the claim with unlisted/unclassified procedure codes. Claims without supporting documentation may be denied. The provider will need to rebill with appropriate documentation.

    Type of Codes and Procedures

    Required Documentation

    All unlisted and unclassified codes billed

    A clear description of the procedure or service

    Laboratory and pathology procedures

    All unlisted codes within the range of 80048–89356: Laboratory and pathology report

    Medical procedures

    All unlisted codes within the range of 90281–99602: Office notes and reports

    Radiology and imaging procedures

    Imaging report

    Surgical procedures

    All unlisted codes within the range of 10021–69990: Operative or procedure report attached to the claim stating what the procedure was and how the procedure was performed

    Unclassified drug "J" codes

    Unlisted J code and NDC number in appropriate fields

    Unlisted DME HCPCS codes

    Invoice along with a narrative on the claim

  • Overpayment Recovery

    Alignment processes overpayment recovery in accordance with CMS regulations or contractual agreements. By law, providers are required to report and return the overpayment to Alignment within sixty (60) calendar days after the date the overpayment was first identified.

    Overpayments occur when too much has been paid to the provider and a refund to Alignment is necessary. For Medicare Advantage plans, overpayments commonly occur due to the following:

    • Duplicate submission of the same service or claim
    • Billing for excessive services or non-covered services
    • Payment for excluded or medically unnecessary services
    • Payment to the incorrect payee
    • Claims-system configuration issues
    • Pricing errors
    • Incorrect adjustments
    • Primary payment when Alignment Health Plan is the secondary payer

    Alignment's look-back period for overpayments will be done in accordance with the time frames permitted by CMS. A prior written notification about the overpayment amount, along with the reason and timeframe for returning overpaid amounts, is provided to the provider. If the provider does not submit a full refund within the timeframe indicated on the written notification, Alignment will process recoupments against future claim payments.

    Providers must mail refund checks, along with a copy of the notification or other supporting documentation, to the address noted in the overpayment recovery letter.