Physician Dispute Resolution
For the following Brown & Toland Medical Group claims, please send to:
Brown & Toland Claims Department
P.O. Box 72710
Oakland, CA 94612-8910
By Fax: Send electronic requests for payment dispute decisions to 415-972-6011
- BTHS Provider Dispute Resolution
- CMS Provider Dispute Resolution
- Commercial Provider Dispute Resolution
For the following Brown & Toland Health Services claims, please send to:
BTHS Claims Department
P.O. Box 70190
Oakland, CA 94612-0190
By Fax: Send electronic requests for payment dispute decisions to 415-972-6011
Policies
- BTMG Provider Dispute Mechanism
- BTMG Medicare Advantage Claims Inquiry Process for Contracted Providers
- BTMG CMS Provider Payment Dispute Resolution Mechanism (non-contracted providers)
Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) will expand its current provider payment dispute resolution process for disputes between non-contracted and deemed providers and Private Fee for Service Plans (PFFS) to include disputes between non-contracted providers and all:
- Medicare Advantage Organizations (HMO, PPO, RPPO and PFFS)
- 1876 Cost Plans
- Medi-Medi Plans
- Program of All-Inclusive Care for the Elderly (PACE) organizations
First Level Review
Providers should send their provider dispute request to Brown & Toland for a first level review. Please see the dispute policies and Provider Dispute Resolution Forms.
**Submission of a first-level provider dispute must be filed within a minimum of 120 calendar days after the notice of initial determination (i.e., Explanation of Benefits/Remittance Advice). (Applies to CMS Provider Dispute Policy (non-contracted) only).
Appeals Process for Non-contracted Medicare Providers
Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination.
To appeal a claim denial, submit a written request within 60 calendar days of the remittance notification date and include at a minimum:
- A statement indicating factual or legal basis for appeal
- A signed Waiver of Liability form (you may obtain a copy on: https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Notices-and-Forms) – Downloads section: “Model Waiver of Liability” or download PDF here
- A copy of the original claim
- A copy of the remittance notice showing the claim denial
- Any additional information, clinical records or documentation
For more information on the CMS PDR process, refer to the CMS Provider Dispute Resolution for non-contracted providers page.
Electronic Payment Appeals Language