Contracted Provider Appeals

Contracted Windsor Health Plan providers may appeal a Windsor Medicare Extra claim payment denial. A contracted Windsor Health Plan provider may also dispute the way in which a claim was processed by the plan. Please select from the list below the type of appeal you seek:

1. Appeals Regarding the Denial of Claim Payment

2. Appeals Regarding Pre-Service Denials

3. Claim Disputes

Appeals Regarding the Denial of Claim Payment

A request for appeal of a denied claim must be filed with the plan within 180 calendar days of the initial Windsor Medicare Extra Explanation of Payment (EOP) informing the provider of the denial.

A contracted provider may file an appeal for the following reasons:

A prior authorization was not obtained
Authorization obtained does not cover the services rendered
Prior authorization was denied by the plan however provider proceeded to render services

To file an appeal (reconsideration) a contracted Windsor Health Plan provider must:

Submit the request within 180 calendar days of the initial EOP
Complete a Contracted Provider Reconsideration (Appeal) Form
Include a detailed explanation supporting request to appeal denial of claim payment
If prior authorization was not obtained because provider was not aware the patient was a Windsor Medicare Extra member, include proof of eligibility verification prior to services being rendered. Proof of eligibility verification prior to the services being rendered must include a copy of the patient registration including a copy of identification cards presented, proof of online Medicare eligibility verification, call log documentation confirming telephonic eligibility verification. If eligibility was not verified prior to the services being rendered, explain why.
Include medical records supporting services rendered
Include copy of claim form
Include copy of Windsor Medicare Extra EOP

Appeals must be mailed to:

Windsor Health Plan, Inc.
Attn: Contracted Provider Appeals
7100 Commerce Way, Suite 285
Brentwood, TN 37027

For your convenience, you may use the Contracted Provider Reconsideration (Appeal) Form to file an appeal with us.

Appeals Regarding Pre-Service Denials

If you are a treating physician wanting to appeal a denial for services a member has not yet received, you may file an appeal on behalf of the member without being the member’s appointed representative. Please refer to the Appeals and Grievances section for information regarding member appeals and how to file an appeal on a member’s behalf regarding pre-service denials.

Claim Disputes

A request to dispute the processing of a claim must be filed with the plan within 180 calendar days of the initial Windsor Medicare Extra Explanation of Payment (EOP).

A provider may dispute the processing of a claim for the following reasons:

Claim denied due to untimely claim filing
Claim paid rate applied resulted in underpayment/overpayment
Claim denied due to lack of prior authorization but services rendered do not require prior authorization
Dispute of Claim Check logic application
Claim denied as not covered by Medicare however provider disputes exclusion from Medicare coverage
Dispute of claim denial due to other primary coverage

To file a claim dispute a provider must:

Submit the request within 180 calendar days of the initial EOP
Complete a Claim Dispute Resolution Form
Include a detailed explanation supporting request to dispute the way the claim was processed
Include a copy of the claim form
If applicable, include a copy of Medicare EOB, Medicare Recoupment Notice, Other Carrier Remit
Include proof of eligibility verification prior to services being rendered if applicable to claim dispute. Proof of eligibility verification prior to the services being rendered must include a copy of the patient registration including a copy of identification cards presented, proof of online Medicare eligibility verification, call log documentation confirming telephonic eligibility verification. If eligibility was not verified prior to the services being rendered, explain why.

Claims disputes must be mailed to:

Windsor Health Plan, Inc.
Attn: Claim Dispute Resolution Department
7100 Commerce Way, Suite 285
Brentwood, TN 37027

For your convenience, you may use the Claim Dispute Resolution Request Form to file a claim dispute with us.

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