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Appeal and Reconsideration Procedures

Community HealthChoices (CHC) Medicaid

Retrospective Authorization Review: Retrospective review is an initial review of services provided to a Participant, but for which authorization and/or timely notification to PA Health & Wellness was not obtained due to extenuating circumstances (i.e. Participant was unconscious at presentation, Participant did not have their Medicaid ID card, or otherwise indicated Medicaid coverage, services authorized by another payer who subsequently determined participant was not eligible at the time of service). Requests for retrospective review must be submitted promptly. A decision will be made within 30 calendar days following receipt of request, not to exceed 90 calendar days from date of service. Presumptive eligibility rules apply.

Medical Necessity Appeal: If authorization or retro-authorization was denied, in part or whole, follow the Appeal process.

Claim Reconsideration: Follow the claim reconsideration process if the claim did not pay as expected, but the claim does not need to be corrected. This can include a request to reconsider authorization denials if an authorization was required and not obtained (justification should be included).

Community HealthChoices Medicaid
Process Mailing Address Notification Timeframe Determination TAT Fax/Phone/Email Web Portal

Pre-Service Authorization

Click for Forms

n/a

CHC Provider Manual

Scheduled Admission: 5 business days

Elective OP: 5 business days

Emergent IP: within 24 hours or next business day

 

Observation (≤23 hours): one business day for non-par

Observation (>23 hours hours): IP auth within 1 business day

ER and post stabilization, urgent care, crisis intervention: 2 business days

Maternity admit: 1 business day with delivery outcome

Newborn admit: 1 business day

Neonatal ICU admit: 1 business day

CHC Provider Manual

Urgent: 72 Hours

Non-Urgent: 2 business days of receipt of all necessary info, not to exceed 14 calendar days

Fax: Follow fax submission directions located on the applicable form(s)

Phone: n/a

Email: n/a

Yes

Concurrent Review

Note: After initial auth, ongoing reviews are done via phone/fax

n/a   1 business day

Fax: Submit ongoing records via fax/phone

Phone: 844-626-6813

Email: n/a

No

Peer-to-Peer

Note: PHW will make 3 attempts to schedule prior to closing/upholding; 2 call attempts by MD prior to closing/upholding

n/a Request P2P within 2 business days of date of denial P2P determination within 1 business day

Fax: n/a

Phone: 844-626-6813

Email: n/a

No

Retrospective Authorization Review

Click for Forms

n/a Request within 90 calendar days from DOS. Determination within 30 calendar days

Fax: Follow fax submission directions located on the applicable form(s)

Phone: 844-626-6813

Email: n/a

Limited based on DOS

Medical Necessity Appeal

 

Note: appeals must be filed within 60 days of the notice of determination. If there is a claim on file, please follow the process for Claim Reconsideration below.

PA Health and Wellness

Attn: C&G Provider Appeal

300 Corporate Center Drive, Ste 600

Camp Hill, PA 17011

 

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

  Determination within 30 calendar days of receipt

Fax: 844-873-7451

Phone: 844-626-6813

Email: PHWComplaints
andGrievances
@PAHealthWellness
.com

No

Claim Reconsideration

Note: if auth/medical necessity denial related, with records attached, will be routed to UM

PA Health and Wellness Attn: Reconsideration

PO Box 5070

Farmington, MO 63640

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

365 days from date of service 30 calendar days

Fax: n/a

Phone: n/a

Email: n/a

Yes

Wellcare By Allwell Medicare (MAPD, D-SNP & PPO)

Appeal: An Appeal is the mechanism which allows Providers the right to appeal actions of Wellcare By Allwell such as a pre-service prior authorization denial. If authorization was denied pre-service or during concurrent review, follow appeal instructions on the notification letter. This process excludes post-service and claims-related disputes. 

Claim Reconsideration: Follow the claim reconsideration process if you disagrees with the original claim outcome (payment amount, denial reason, etc.). The reconsideration process can be followed if an authorization was not obtained or if the member has been discharged/services already rendered. Submit claim along with supporting medical records/documentation and reason for late notification or lack of prior authorization, as appropriate.

Claim Dispute: Follow the claim dispute process if there is disagreement with the outcome of the Reconsideration process.

Retrospective Review:  A retrospective review is any review of care or services that have already been provided to a Member and requires the submission of a claim. This includes acute hospital stays when initial notification is received after the Member has been discharged. The requestor must submit a claim for payment with supportive documentation as applicable (i.e. medical records to support clinical review, certificate of Medical Necessity, consent forms or invoices). If the claim is denied, the Provider will have the ability to file a claim reconsideration.

Wellcare by Allwell Medicare (MAPD, D-SNAP and PPO)
Process Mailing Address Determination TAT Fax/Phone/Email Web Portal

Pre-Service Authorization

Click for Forms

n/a See charts in the Wellcare by Allwell Provider Manual for determination timeframes

Fax: Follow fax submission directions located on the applicable form(s)

Phone: HMO: 855-766-1456

HMO SNP: 866-330-9368

Email: n/a

Yes
Concurrent Authorization n/a  

Fax: Fax supporting clinical

Phone: HMO: 855-766-1456

 

HMO SNP: 866-330-9368

Email: n/a

No
Peer-to-Peer n/a  

Fax: n/a

Phone: 1-833-456-8216

Email: n/a

No

Appeal

(pre-service/concurrent denial)

Note: Always follow instructions in denial letter.

Centene Corporation

Attn: Grievances & Appeals Medicare Operations

7700 Forsyth Blvd.

Saint Louis, MO 63105

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: 844-273-2671

Phone: HMO: 855-766-1456

 

HMO SNP: 866-330-9368

Email: n/a

No
Claim Submission

Wellcare by Allwell

Attn: Claims

PO Box 3060

Farmington, MO 63640-3822

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: n/a

Phone: n/a

Email: n/a

Yes

Claim Reconsideration

Note: Can be post-service or post-discharge with Medical Records if incorrect/no authorization obtained (include reason for not obtaining auth within required notification timeframe)

If filing by mail, must use dedicated forms:

Wellcare by Allwell

Attn: Request for Reconsideration

PO Box 3060

Farmington, MO 63640-3822

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: n/a

Phone: n/a

Email: n/a

Yes
Claim Dispute

Wellcare by Allwell

Attn: Claim Dispute

PO Box 4000

Farmington, MO 63640-4400

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: n/a

Phone: n/a

Email: n/a

No

Ambetter Marketplace (Commercial Exchange)

Member Appeal: If authorization was denied pre-service or during concurrent review. This process excludes post-service and claims-related disputes. Pre-service Member Appeals must follow the Appeal process below. A member must designate in writing to Ambetter for a provider to act on behalf of the member regarding the appeal process.

Claim Reconsideration: A request for reconsideration is a communication from the provider about a disagreement with the manner in which a claim was processed. Generally, medical records are not required for a request for reconsideration. However, if the request for reconsideration is related to a code audit, code edit, or authorization denial, medical records must accompany the request for reconsideration. If the medical records are not received, the original denial will be upheld.

Claim Dispute: Follow the claim dispute process if there is disagreement with the outcome of the Reconsideration process.

Ambetter Marketplace (Commercial Exchange)
Process Mailing Address TAT Fax/Phone/Email Web Portal

Pre-Service Authorization

Click for Forms

n/a See charts in the Ambetter Provider Manual for determination timeframes

Fax: Follow fax submission directions located on the applicable form(s)

Phone: n/a

Email: n/a

Yes
Concurrent Authorization n/a  

Fax: n/a

Phone: n/a

Email: n/a

 
Peer-to-Peer n/a  

Fax: n/a

Phone: 1-833-456-7956

Email: n/a

 

Member Appeal

Note: A member must designate in writing to Ambetter for a provider to act on behalf of the member regarding the appeal process. Follow instructions in the authorization determination letter

Member appeals and appeals o nmembers' behalf:

Ambetter from PA Health and Wellness
PO Box 10341
Van Nuys, CA 91410

Fax 1-833-886-7956

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: 833-886-7956

Phone: 833-510-4727

Email: n/a

No
Claim Submission

Ambetter

Attn: Claims

PO Box 5010

Farmington, MO 63640

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: n/a

Phone: 833-510-4727

Email: n/a

Yes

Claim Reconsideration

Note: Generally, medical records are not required for a request for reconsideration. However, if the request for reconsideration is related to a code audit, code edit, or authorization denial, medical records must accompany the request for reconsideration. If the medical records are not received, the original denial will be upheld.

Ambetter

Attn: Request for Reconsideration

PO Box 5010

Farmington, MO 63640

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: n/a

Phone: 833-510-4727

Email: n/a

Yes
Claim Dispute

Ambetter

Attn: Claim Dispute

PO Box 5000

Farmington, MO 63640

NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.

 

Fax: n/a

Phone: 833-510-4727

Email: n/a

No