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Model Waiver of Liability form
A Medicare Advantage non-contract provider has the right to request a reconsideration of the Medicare Advantage plan’s denial of payment,
but must submit a Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.