Sunday, June 6, 2010

Claims Appeal Process - Peach state health plan

Claims Adjustment:

* Providers may resubmit a claim(s) to correct a simple billing error or to request an adjustment if you believe the payment made by the plan is incorrect. In order to be considered for payment claims in this category must be received within six (6) months from the month in which the service was rendered or within three (3) months of the month of payment on the EOP, which is later. Please include the word “resubmission” and the claim number on the claim form to help us identify that this is a resubmission of an existing claim. A Provider
Adjustment form must be completed for all resubmission requests along with the supporting documentation. Your claim will be reviewed and a decision rendered based on the information provided.

* Requests for Claim Adjustments that involve like or similar issues may be batched together using one Provider Adjustment Request Form (located on the web site) for dates of service after July 1, 2008. The form should clearly describe the issue with all supporting documentation attached and indicate the number of claims included.

Peach State Health Plan
P.O. Box 3030
Farmington, MO 63640-3800

Claims Appeals:

*  If you are not satisfied with result of your Claim Adjustment request, you may submit a written appeal within 30 days of the decision. You will receive acknowledgement of your written appeal within 10 days of receipt. Appeals received after the thirty (30) day time frame will not be considered for failure to appeal within the time frame.

*  Peach State will allow providers to batch multiple claim appeals for claims with dates of service after July 1, 2008 that are similar in nature submitted under the same Appeal Letter. The Letter of Appeal must indicate the nature of the complaint and the number of items attached.

*  A decision will be rendered within thirty (30) days of receipt of the appeal and you will receive notification of the decision via the EOP notice or written correspondence. Provider Appeals should be mailed to:
Peach State Health Plan
Attn: Provider Appeals
P.O. Box 3000
Farmington, MO 63640-3800

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