Contracted Provider Appeals

Providers may appeal Windsor Medicare Extra decisions regarding both medical necessity determinations and claims adjudication. Please select from the list below the type of appeal you seek:

1. Appeals Regarding Medical Necessity Determinations (Medical Appeals)

2. Appeals Regarding Claims

Appeals Regarding Medical Necessity Determinations (Medical Appeals)

To file an appeal regarding a denial of authorization of medical necessity, please include the following in your correspondence:

Cover Letter with specific request and explanation of extenuating circumstances.

Supporting documentation (medical records, etc.)

Claim Form.

Windsor denial remittance advice (if applicable).

Proof of eligibility verification or explanation of why eligibility verification was not obtained.

Appeals must be mailed to:

Windsor Medicare Extra
Attn: Medical Appeals
7100 Commerce Way
Suite 285
Brentwood, TN 37027

Please refer to the Appeals and Grievances section for information regarding member appeals and how to file an appeal on a member’s behalf.

Appeals Regarding Claims

To file an appeal regarding a denied claim, please include the following in your correspondence:

Cover Letter with specific request and any necessary supporting documentation.

Claim Form.

Windsor denial remittance advice.

Proof of eligibility verification or explanation of why eligible verification was not obtained.

Appeals must be mailed to:

Windsor Medicare Extra
Attn: Claims Appeals Department
7100 Commerce Way
Suite 285
Brentwood, TN 37027

Non-Contracted Provider Appeals

1. What happens if Windsor Medicare Extra denies a request for claim payment from a non-contracted provider?

2. How to file an appeal

3. How soon must we decide on your appeal?

4. Questions about the appeals processes or case status

What happens if Windsor Medicare Extra denies a request for claim payment from a non-contracted provider?

If Windsor Medicare Extra denies a request for payment of a claim from a non-contracted provider, the non-contracted provider can file a standard appeal on his or her own behalf within 60 calendar days from the date on the original Explanation of Payment received by the non-contracted provider.

How to file an appeal

A non-contracted provider may request a standard appeal for a denied claim by filing a signed, written request with the plan. A non-contracted provider may file an appeal only if the provider completes a Waiver of Liability Statement. The Waiver of Liability Statement provides that the provider will not bill the Windsor Medicare Extra enrollee regardless of the outcome of the appeal. Signing the waiver does not negate the non-contracted provider's right to request further appeal under 42 CFR 422.600.

We ask that you include any supporting evidence for your appeal, such as medical records for the date(s) of service in question, with your request. Remember, appeals must be filed within 60 calendar days from the date of Windsor Medicare Extra's initial denial of payment.

Waiver of Liability Statement

You may mail your signed, written requests for appeal to us at:

Windsor Medicare Extra
Attn: Non-Contracted Provider Appeals
7100 Commerce Way
Suite 285
Brentwood, TN 37027

For your convenience, you may use the Non-Contracted Provider Appeal Form to file an appeal with us.

How soon must we decide on your appeal?

The time frame for acting on a timely appeal request begins when the properly executed Waiver of Liability Statement form is received by Windsor Medicare Extra.

If, upon appeal, Windsor Medicare Extra overturns its initial claim denial, we will mail you a decision and send payment for the service within 60 calendar days from the date we received the Waiver of Liability Statement form.

If, upon appeal, Windsor Medicare Extra upholds the initial denial, in whole or in part, we will mail you a decision and forward a complete copy of the case file to the Independent Review Entity contracted by the Centers for Medicare and Medicaid Services within 60 calendar days from the date we received the Waiver of Liability Statement form for an independent review of Windsor Medicare Extra's adverse appeal decision.

Questions about the appeals processes or case status

Calls to these numbers are free:
Phone: 1-800-316-2273
TTY/TDD: 1-800-848-0298