The information contained on this page outlines the necessary process for a non-contracted provider who wishes to
dispute payment issued by Triad. The provider payment dispute process should be used when a non-contracted
provider contends that the amount paid by Triad for a covered service is less than the amount that would have
been paid under Original Medicare. (See §§1852(a)(2)(A) of the Act for Medicare Advantage plans).
Provider payment disputes can also include instances where there is a disagreement between a non-contracted
provider and our decision to make payment on a more appropriate code. The provider payment dispute process
does not include:
- Payment denials issued by Triad that result in zero payments being made to a non-contracted provider.
- Payment disputes for contracted providers.
- Local and National Coverage Determinations.
- Medical necessity determinations.
- Payment disputes for which no initial determination has been made.
Submission Guidelines:
Non-Contracted providers can submit a Provider Dispute Resolution Request (PDR) directly to Triad Healthcare
via fax, 860-793-3317, or by mail to Triad HealthCare Inc., 80 Spring Lane, Plainville CT 06062.
When submitting a PDR please include the following information: Provider name, Provider NPI, Provider Address,
Patient name, Patient DOB, Patient Health Plan ID#, Original claim ID#, Service date, Original claim amount
billed, Original claim amount paid, description of the dispute, expected outcome, contact name & contact
phone number.
Submission of the first level Provider Dispute must be filed within 120 calendar days after the notice of
initial determination from Triad.
Triad will issue resolution in writing within 30 calendar days from receipt of the Provider Dispute Resolution
Request.
Second Level:
The non-contracted provider may submit a second level written request (http://www.iceforhealth.org/library.asp?sf=&scid=2314#scid2314) for an Independent Payment Dispute Decision (PDD) to C2C Solutions, Inc. (C2C) by email, fax or mail within 180 calendar days of written notice from Triad.
For additional information please reference the ICE and CMS websites:
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