Section 1011 Payment Dispute Process

A dispute resolution process for the Section 1011 program has been established to give providers an opportunity to seek further information regarding Section 1011 payment decisions. Page 66 of the Section 1011 Final Policy reads, “While we are not adopting a formal appeals process, we believe that providers should have an avenue to address payment disputes.”

Providers may dispute decisions for payment requests that have been partially or fully denied. Providers may not challenge the payment methodology established in the Final Policy Notice.

Dispute Request Form

To dispute a payment request that was partially or fully denied, providers should submit a written dispute request form and include the following information:

• Provider’s name
• Section 1011 Provider Identification Number (PIN)
• Patient Identifier Number (HIC)
• Document Control Number (DCN)
• Full date range of service
• Specific date(s) of items in dispute
• Original amount submitted for reimbursement
• Denied service and reason for dispute
• Requester’s contact information including name, title, telephone number, e-mail address and signature
• Date of signature
• Letter of representation (if submitter is an entity other than the provider)
• Appropriate documentation to support the dispute.

Time Requirement

Providers should submit the Dispute Request form no later than 45 days after the quarterly payment date for the quarter in which the disputed payment request was billed or no later than 45 days after the quarterly payment date in which any postpayment activity was taken on the payment request in question. TrailBlazer may grant an exception to this deadline if a provider can show a good faith effort was made to meet the requirement, but was prevented from doing so due to uncontrollable circumstances.

Click here to view the Section 1011 Dispute Request Cycles

Mail dispute request forms to the following address:

TrailBlazer Health Enterprises, LLC
Attn: Section 1011 Dispute Resolution
P.O. Box 660529
Dallas, TX 75266-0529

TrailBlazer does not send an acknowledgement of receipt. Providers may not appeal finalized disputes.

Section 1011 Payment Dispute Review, Decisions, Notifications, Timelines and Resolutions

Dismissals

Trailblazer will dismiss all incomplete and non-allowable payment disputes and will notify providers of this decision via e-mail within 45 days of receipt of the dispute. The dispute dismissal e-mail will identify the following:

• Full dates of service of original payment request (if one has been submitted)
• Items/services and amounts disputed by the provider
• Payment dispute decision (dismissal)
• Reason for dismissal

Dismissals that are returned as undeliverable e-mails will be mailed to the requester identified on the provider Dispute Request form, via United States Postal Service (USPS).

Dispute Review and Resolution

Review of a provider payment dispute may result in one of three decisions:

1. Uphold the original payment decision (“Uphold”).
2. Reverse the original payment decision in full (“Full Reversal”).
3. Reverse the original payment decision in part (“Partial Reversal”).

TrailBlazer will review the documentation furnished by the provider and if the documentation supports the payment of any disputed item(s) or service(s), TrailBlazer will reverse the original payment decision on those item(s) or service(s) and issue a provider payment. In cases where the documentation does not support the payment of any disputed item(s) or service(s), TrailBlazer will uphold the original payment decision, and no provider payment will be made.

Notification of Decision

TrailBlazer will adjudicate all (non-dismissed) provider payment disputes and notify providers of the decision via e-mail within 45 days of receipt of a written payment dispute. The dispute notification e-mail will identify the following:

• Full dates of service of original payment request
• Denied services and amounts disputed by the provider
• Payment dispute decision and resolution
• Explanation of the decision and resolution

Decisions that are returned as undeliverable e-mails will be mailed to the requester identified on the provider Dispute Request form, via United States Postal Service (USPS).

Timing and Calculation of Payments made due to Provider Dispute

TrailBlazer will pay amounts due to providers resulting from the resolution of a provider dispute in the quarter following resolution. Such payments are subject to the rates and pro-rata reduction applicable in which the resolved dispute is paid.