Appeal & Dispute Procedures
PROVIDER APPEALS & DISPUTES PROCESS
PA Health & Wellness (PHW) recognizes that there are times when providers may not be satisfied with a matter handled by PA Health & Wellness. Providers have a right to file an appeal or dispute. A Health & Wellness maintains a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes and a formal process for Provider Appeals.
*This process excludes claims reconsiderations or disputes – see section 3 for claims specific information.
*This process excludes Participant complaints and grievances.
A Provider Appeal — A written request from a Provider for reversal of a determination by the PA Health & Wellness, including but not limited to:
- Prior Authorization denial
- Adverse credentialing decision
- Decision about a Quality of Care Complaint
- Decision to sanction a Provider
- Decision to terminate the Provider’s contract with PHW
Provider Dispute — A written communication to PA Health & Wellness, made by a Provider, expressing dissatisfaction with a PA Health & Wellness decision that directly impacts the Provider, excluding decisions concerning Medical Necessity.
Providers are allowed Thirty (30) days from the date of receipt of the decision to file a dispute. If the issue being disputed is associated with dissatisfaction with PHW Policies or Procedures, the Provider should file a dispute within Thirty (30) Days of becoming aware of the issue.
PA Health & Wellness requires that all complaints received from providers be submitted to PA Health & Wellness in writing. PA Health & Wellness offers a number of ways to file a written Dispute or Appeal, as listed below:
- Faxing, mailing, or emailing a Provider Dispute/Appeal Form (PDF) or a written Appeal or Dispute to PA Health & Wellness:
Attn: Complaints and Grievances Unit
300 Corporate Center Drive, Suite 600
Camp Hill, PA 17011
- For help filing a Provider Dispute or Appeal, please contact our Complaint and Grievance Department:
PA Health & Wellness reviews the dispute to ensure that it has been filed within the required 30 days. If it has not, then PA Health & Wellness sends written notice to the provider that the dispute is not timely filed.
PA Health & Wellness then has thirty (30) calendar days to resolve the dispute. The response to the dispute will be provided in writing in the form of a resolution letter.
It is important to note that inquiries or appeals related to claims are handled separately from provider appeals or disputes. Please review the PA Health & Wellness CHC Provider Billing Manual (PDF) for the process for claims reconsideration and disputes. Claims status can be viewed via the PA Health & Wellness Secure Provider Portal. For claims status inquiries contact PA Health & Wellness’s Provider Services team by calling 1-844-626-6813.
All claim requests for reconsideration, corrected claims or claim disputes must be received within 365 calendar days from the date of the Explanation of Payment (EOP). If a provider has a question or is not satisfied with the information they have received related to a claim, there are four (4) effective ways in which the provider can contact PA Health & Wellness.
- Contact a PA Health & Wellness Provider Service Representative: 1-844-626-6813
- Providers may discuss questions with PA Health & Wellness Provider Services Representatives regarding amount reimbursed or denial of a particular service.
- Submit an Adjusted or Corrected Claim.
- Submit a Request for Reconsideration:
- A request for consideration is a written communication from the provider about a disagreement in the way a claim was processed, but does not require a claim to be corrected and does not require medical review.
- Requests for reconsideration should be sent along with the
- PA Health & Wellness Reconsideration form (PDF).
- The documentation must also include a detailed description of the reason for the request and any additional supporting documentation.
- If the request results in an adjusted claim, the provider will receive a revised EOP.
- If the original decision is upheld, the provider will receive a revised EOP or a letter detailing the decision and steps for escalated reconsideration.
- PA Health & Wellness shall process and finalize all adjusted claims, requests for reconsideration and disputed claimes to a paid or denied status 30 business days of receipt of the request.
- Submit a Claim Dispute:
- A Claim Dispute is a formal written request for PA Health & Wellness to dispute the decision made during the request for reconsideration process.
- Disputes must be submitted along with the PA Health & Wellness Dispute form (PDF)
- PA Health & Wellness will make reasonable efforts to resolve all requests within 30 calendar days of receipt. Based upon the information submitted, they will either uphold the original decision or overturn the original decision.
- If the original decision is upheld, you will be sent a letter stating the reason(s) for the decision.
- If the original decision is overturned, you will receive a letter stating PA Health & Wellness' decision and any additional payment due will appear on your remittance.