Non-Contracted Provider Appeals

Appeals of Claim Denials and/or Medical Necessity Denials  
(not related to retrospective audits)  
Calling Provider Inquiry Services is the first step in addressing a concern. If you are still unhappy with the decision after speaking with a representative, you may appeal decisions on denied claims, such as denial of a service related to medical necessity and appropriateness by following the member appeals process.  

Non-contracted providers may submit an appeal in writing to: 

Non-contracted providers appealing claim/medical necessity denials must sign a waiver of liability. The waiver of liability indicates that you formally agree to waive any right to payment from the member for the service in question regardless of the outcome of your appeal.  

Appeals must be submitted within 65 days of the denial from the date the of the initial denial notice. Be sure to include appropriate documentation to support your appeal. We will review your appeal and respond to you in writing within 60 days from the date we receive your appeal request. 

Appropriate documentation needed for a medical necessity appeal review:  

• Provider or supplier contact information including name and address 
• Pricing information, including NPI number (and CCN or OSCAR number for institutional providers), ZIP code where services were rendered and physician specialty 
• Reason for dispute -- a description of the specific issue 
• Copy of the provider’s submitted claim with disputed portion identified 
• Documentation and any correspondence that supports your position that the plan’s denial was incorrect (including clinical rationale, Local Coverage Determination and/or National Coverage Determination documentation) 
• Appointment of provider or supplier representative authorization statement, if applicable 
• Name and signature of the provider or provider’s representative