Waiver of liability
Waiver of liability notice
Notice requirements for CMS non-contracted provider appeals for zero net payment — MMCM Chapter 13, 40.2.3
Non-contracted providers have the right to request a reconsideration for denial of payment within 60 calendar days from the remittance notification date to file the reconsideration.
A signed waiver of liability form holding the enrollee harmless regardless of the outcome of the appeal is required. Please complete the waiver of liability and submit to the health plan.