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

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.

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:

• (360) 975-7000, option 1
• Or send an email to info@officeally.com
• Or visit the Office Ally website for more info: https://cms.officeally.com/

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

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

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.

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:

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.

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.

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.

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.

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.

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.

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.

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.

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.

Alignment contracted with Payspan to provide providers access to remittance advice electronically, giving providers the option to receive payment via Electronic Fund Transfers (EFT). Providers may register through Payspan to receive electronic services.

To register with Payspan:

• Go to payspanhealth.com/nps
• Contact Payspan at:
  • 1-877-331-7154
  • Email: Provider Support

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.

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.

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.