The following is suggested wording to be included in the MAO’s unfavorable payment dispute decisions to non-contracted or deemed providers. Contracted providers’ disputes may not be handled under this resolution process.

Note that denials subject to the Part 422 managed care beneficiary appeals process (those denials where no payment has been made, possibly resulting in either a beneficiary appeal or the provider submitting a waiver of liability and appealing under the Part 422 process) should not be directed to C2C Solutions, Inc. (C2C). Payment disputes that may be resolved by C2C include those instances where reimbursement for the service has been allowed or is included in the reimbursement of another service and may include those instances where the MAO reimbursed a different service than that billed, often referred to as down-coding of claims.

If you believe that MAO plan name reached an incorrect decision regarding your payment dispute, you may file a request for review of that determination with C2C Solutions, Inc. (C2C), an independent entity contracted by CMS to act as the Payment Dispute Resolution Contractor (PDRC). C2C can receive payment dispute decision requests via the following media:

• E-mail. 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 e-mail box at PDRC@C2Cinc.com. Otherwise, you may submit payment dispute decision requests (including associated documents such as claims forms that may contain PHI) via the methods outlined below.

• Fax. Fax electronic requests for payment dispute decisions to (904) 361-0551

• Mail. Providers can mail hard copy requests for payment dispute decisions to the following address:

C2C Solutions, Inc.

Payment Dispute Resolution Contractor

P.O. Box 44017

Jacksonville, Florida 32231-4017

Before submitting a request with C2C Solutions, Inc., please review their webpage for additional information and a copy of the request form: www.C2Cinc.com/QIC PDRC. Submit all required documentation with your request to avoid having your request dismissed or delayed. If you have questions about MAO plan name’s decision, you may contact us at _______________________.