MA Affidavit – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Interest Owed on Late Claims 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,... View more
MA Affidavit – Maternity Coverage
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Maternity Services 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 45 CFR §146.130(a) which states:... View more
MA Affidavit – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Medical Necessity 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 §422.590, which states:... View more
MA Affidavit – Misdirected Claims
Last Updated: May 24, 2020 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Misdirected Claim 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 §422.504(i), which states:... View more
MA Affidavit – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Emergency and Urgently Needed Services 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... View more
MA Affidavit – No Claim on File
Last Updated: May 23, 2020 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE No Claim on File 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 45 CFR §164.530(c),... View more
MA Affidavit – No Contract Underpayment
Last Updated: November 19, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Payment to Non-Contract 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 §422.216... View more
MA Affidavit – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Notice Requirements for Adverse Determinations 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... View more
MA Affidavit – Poststabilization Timeframe
Last Updated: May 23, 2020 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Poststabilization Care Services 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 §422.113(c), which... View more
MA Affidavit – Refund Recoupment – Reducing LOC
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: MA
AFFIDAVIT OF COMPLIANCE Recoupment-Reducing LOC 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 Medicare Managed Care Manual, Chapter... View more