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CMS Non-contracted Provider Appeal Process

Non-contracted providers have the right to request a CMS appeal for denial of payment ( ZERO PAY) within 60 calendar days from the remittance notification date. A signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal is required and must be sent in with all CMS appeal requests.

        CMS Waiver of Liability Form.pdf *

The Medicare Managed Care Manual (MMCM) and Waiver of Liability form can also be found at: *

When submitting a CMS appeal/reconsideration request, you must include any and all pertinent documentation to support your appeal; such as a copy of the original claim, remittance notification showing the denial, any clinical records and other documentation that supports your argument for reimbursement. Please keep in mind that if the Waiver of Liability is not received along with all supporting documentation when sent to the Health Plan, your case may be sent for dismissal.

Please submit all CMS appeal/reconsideration requests to the addresses below for the following Health Plans:

Aetna Medicare Health Plan
Appeals & Grievance Unit
P.O. Box 14067
Lexington, KY 40512
Fax: 866-604-7092

Anthem Blue Cross
Grievances and Appeals
OH0205-A537 Mail Location
4361 Irwin Simpson Rd
Mason, OH 45040-9392

Blue Shield
Appeals & Grievance Unit
P.O. Box 272540
Chico, CA 95927-2540

United Healthcare
Provider Dispute & Appeals
P.O. Box 30764
Salt Lake City, UT 84130-0764

Care 1st
Attn: PDR Department
P.O. Box 3829
Montebello, CA 90640

Easy Choice Health Plan, Inc
Appeals & Grievance Unit
P.O. Box 260519
Plano, TX 75026-0519

Health Net Medicare Appeals
Appeals & Grievance Unit
P.O. Box 10406
Van Nuys, CA 91410

Humana, Inc.
Appeals & Grievance Unit
P.O. Box 14165
Lexington, KY 40512-4165
Fax: 800-949-2961

Appeals & Grievance Unit
P.O. Box 4319
Rancho Cucamonga, CA 91729-4319

SCAN Claims Department
Appeals & Grievance Unit
P.O. Box 22698
Long Beach, CA 90801-5616

All other reconsideration requests should be sent to NAMM:

  • Provider Dispute Resolution Department
    P.O. Box 6902
    Rancho Cucamonga, CA 91729-6902


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