Dear Provider:
Secure Horizons®/Oxford - MedicareCompletePlans has been notified that you would like to become a party to an appeal for one of our Members. Since you are a non-participating provider with us, in order to appeal the claims denial, you must become a party to the appeal by completing a Waiver of Liability Statement.
Your APPEAL and WAIVER OF LIABILITY STATEMENT must be received by Secure Horizons®/Oxford’s Medicare Complaints, Appeals & Grievances (MCAG) Department within 60 days of the original denial. We will review your request and notify you in writing of its decision within the applicable time frame once the documentation is received. This form may be duplicated for multiple submissions. We cannot process your original request without the required documentation.
WAIVER OF LIABILITY STATEMENTMember’s Name:______ID ______*01
Claim # Dos:
Claim # Dos:
Claim # Dos:
I hereby waive any right to collect payment from the above-mentioned enrollee for the aforementioned services for which payment has been denied. I understand that the signing of this waiver does not negate my right to request further appeal under 42 CFR 422.600.
Signature: ______/ Date: ______
Print Name:______/ Title:______
Please complete the above Waiver of Liability Statement and attach it to your appeal request.
Your appeal request should include all applicable information for us to review your appeal, including any applicable medical records and identification of the referring physician.
Please mail your Appeal, Waiver of Liability Statement and all applicable records to:
Secure Horizons®/Oxford’s MedicareCompletePlans
Medicare Complaints, Appeals & Grievances (MCAG) Department
PO Box 7070
Bridgeport, CT 06611
MS-06-417
04/06