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:
- Denials of Claims and payment of Claims at an alternate level of care than what was provided, i.e., acute versus skilled days. This includes the appeal by a Provider of a CHC-MCO’s decision to deny payment for services already rendered by the Provider to a Participant.
- QM/UM sanctions.
- Adverse credentialing/re-credentialing decisions.
- Provider Terminations.
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 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 service. 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.