Tuesday, November 30, 2010

Process involved in denial claim appeal

The appeal process

Informal review

When the insurance has denied a claim, contact your Provider Representative for an informal review. If you are not satisfied with the outcome of the informal review, you may bring your concern to a formal review process.

Level I review

To initiate a formal Level I review, complete an appeal form (above). Clearly mark the reason you are asking for a review so that processing will not be delayed.

  • You must include supporting documentation for us to review your request. Go to documentation requirements.

  • Mail the form and supporting notes or documents to the address on the form.
  • Insurance specialists will research and compile the necessary contractual, benefit, claims and medical record information. The collected information will be used to construct a chronology of events with all pertinent dates.
  • If you are appealing a procedure that has been labeled "not medically necessary," your appeal will be forwarded to a Team Manager for review.
  • The Medical Director who made the initial decision for further review will review the case. If the appeal is overturned, we will send you a letter. If the Medical Director does not find an indication for overturning the denial, then the information is sent to the Chief Medical Officer for review and decision within 30 days of receipt of the appeal.
  • If the claims upholds the denial, you will be informed of the process you will need to follow to file a Level II appeal.
Level II appeals

  • You must appeal the Level I decision within 30 days. Complete a Level II appeal form (above) with any additional documentation and re-submit it to the address on the form.
  • Appropriate insurance directors, officers, and/or third-party consultants will make a decision on your Level II appeal within 30 days of receipt and inform you of the outcome of the review by letter within five working days of the decision.
  • This decision is final.
In medical reviews the following options:

  • Make an immediate decision using the available information
  • Consult medical directors for additional input
  • Refer the case for independent peer review
  • Refer the case to the UM/QM committee

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