Overview

The plan's provider dispute resolution process ensures correct routing and timely consideration of provider disputes or appeals. The provider dispute process is used to address participating provider's complaints alleging nonpayment for covered services rendered or denial of coverage for what the participating provider believes to be a covered service. Use this process to:

• Appeal, challenge or request reconsideration of a claim (including a bundled group of similar claims) that has been denied or adjusted by the plan.
• Respond to a contested claim that the participating provider does not agree requires additional information for adjudication. A contested claim is one for which the plan needs more information in order to process the claim.
• Challenge a request by the plan for reimbursement for an overpayment of a claim.
• Appeal a participating physician group's (PPG's) written determination following its dispute resolution process when the dispute involves an issue of medical necessity or utilization review, to the plan for a de novo review within 365 days of the PPG's written determination.
• Challenge PPG or hospital liability for medical services and payments that are the result of the plan decisions arising from member grievances, appeals and other member services actions.
• Challenge capitation deductions that are the result of the plan decisions arising from member billings, claims or member eligibility determinations.

The plan does not charge providers who submit appeals to the Provider Services Center for processing provider appeals and does not discriminate or retaliate against a participating provider who uses the provider dispute process. Further, providers participating through a PPG cannot be charged a processing fee when utilizing the PPG's provider dispute process. Contract disputes between participating providers and their PPGs are included within the scope of this section on provider appeals.

Disputes regarding the denial of a referral or a prior authorization request are considered member appeals. Although participating providers may appeal such a denial on a member's behalf, the member appeal process must be followed.

Appeal Procedures

Participating provider appeals must be submitted to the plan or the PPG, depending on contractual relationship, within the timeliness guidelines stated in the Provider Participation Agreement (PPA). If the PPA does not stipulate a specific time frame, the timely filing period includes the year of the date of service plus 365 days.

Provider appeals (PDF) submitted directly by the participating provider or by parties acting on behalf of the participating provider, such as attorneys and collection agencies, are considered appeals.

A written letter of appeal and supporting documentation must be included with the appeal request. Incomplete records delay the review process.

Member appeals follow different and separate guidelines.