MA Affidavit – Untimely Payment

Click here for help.


Payment to Providers

Incorporated by Reference in 28 US Code § 1746


Patient/Multiple Patients:         DOS:

I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Medicare Advantage Organization/Plan or Contracted Entity has met the provisions of 42 CFR §422.520 (a), which states:

(1) The contract between CMS and the MA organization must provide that the MA organization will pay 95 percent of the “clean claims” within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an MA private fee-for-service plan or are claims for services that are not furnished under a written agreement between the organization and the provider.

(2) The MA organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 1816(c)(2)(B) and 1842(c)(2)(B).

I fully understand that claims paid beyond the above statutory timeframes must include interest pursuant to sections 1816(c)(2)(B) and 1842(c)(2)(B).

I fully understand that this affidavit constitutes an official statement under penalty of perjury under the laws of the United States subject to possible audit and investigation by the Centers for Medicare and Medicaid Services (CMS).

I fully understand that CMS may terminate a contract for any of the reasons under 42 CFR § 422.510, and any intentional false execution of this affidavit may constitute a basis for disciplinary action against the plan.


Medicare Advantage Organization/Plan or Contracted Entity:



Plan Administrator/Employee’s Signature:



Plan Administrator/Employee’s Title:





DISCLAIMER: RevAssurance services do not constitute legal advice or legal consultation and do not establish an attorney-client relationship. The determination of the need for legal services and the choice of legal counsel are the sole responsibility of the Provider. You are encouraged to seek independent legal advice at your sole discretion.

RevAssurance does not collect any Personal Health Information. All data transmission has been disabled on this page, in compliance with Federal HIPAA Regulations.