Sunday, June 6, 2010

What are standard appeal and Expedited appeal

Standard Appeals are for services that have already been rendered or for services that are not emergently or urgently needed.
Expedited Appeals are for circumstances when waiting the standard timeframe for an appeal determination could jeopardize the life or health of the member, or the member’s ability to regain maximum function. Expedited appeals are only used for pre-service appeals. This includes situations where a denial has been issued and member remains on an inpatient unit.

Appeal Request Forms: In this packet, you will find separate forms for requesting a standard appeal (page 2) or an expedited appeal (page 3). Each form contains specific submission guidelines. Use of these forms is not required, but will help ensure prompt resolution.

If you do not use the appeal request forms, you must provide a signed cover letter with the following minimum
 A request for appeal or reconsideration of a denial,
 Your name, address, and phone number;
 The member’s name, DOB, and policy number;
 Dates and types of services requested, and the provider rendering the service;
 Reason that you are requesting appeal or believe denial should be overturned.

Appeal requests that do not contain sufficient information will not be processed.
If you choose not to use the expedited appeal request form and would like to request an expedited appeal, you must clearly communicate in the cover letter that you are requesting expedited status.

Supporting Documentation: All appeal requests should include clinical documentation and other pertinent information that supports the need for the requested service. For examples, see page 2.

Submission Deadlines: In most cases, providers have 90 days from the initial notice of denial to file a request for appeal. Please check your denial notice, contract, and provider handbook for details.

Appeals Address: The address for submission is on page 2 or 3, depending on type of appeal. Please include the word “Appeals” in the address line for correct routing and prompt resolution.

Non Network Providers: If you are not a WellCare/ Harmony network provider- and you have not completed a single

case agreement- you must complete and send the Waiver of Liability Form on page 4 in order for your appeal to be processed. This applies only to Medicare members. If you have completed a single case agreement, please include a copy with your appeal.
Appeal Outcomes: An appeal determination letter will be mailed to the appealing party for all processed appeals. We do not take routine verbal requests for status updates.
Claims Appeals: This appeal packet is for appeals of services where authorization was denied or claims were not paid as a result of lack of authorization. If you are seeking to appeal the specific amount that was paid on a claim (that is unrelated to whether the service was authorized), or contest a claim denial for untimely filing, then please address your appeal directly to: WellCare Claims Appeals, P O Box 31372, Tampa, FL 33631-3372. If further authorization is required to effect claims payment, then please use the appropriate address below.

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