Out of Network Provider Appeal Process for Denied Claims


Date Issued: 7/25/2013

Out-of-network providers are permitted to file a standard appeal for a denied Medicare Advantage claim only if they complete a waiver of liability. This waiver states they will not bill the member regardless of the outcome of the appeal.

Appeals must be submitted within 60 calendar days of the date on the notice of the denial and include:

  • a waiver of liability form
  • a copy of the original claim
  • the member name
  • the patient name, date of birth and relationship to the member
  • the member ID number
  • the claim number
  • a copy of the notice of denial
  • any additional documentation relevant to your grievance, including related invoices

Out-of-network provider appeals for denied claims should be sent to:

PO Box 2807 
New York, NY 10116-2807