Appeal & Dispute Procedures
PROVIDER APPEALS AND DISPUTES PROCESS
PA Health and Wellness (PHW) recognizes that there are times when providers may not be satisfied with a matter handled by PA Health and Wellness. Providers have a right to file an appeal or dispute. PA Health and 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 and Wellness, including but not limited to:
- QM/UM sanctions.
- Adverse credentialing/re-credentialing decisions.
- Provider Terminations.
- It is important to note that inquiries or appeals related to claims are handled separately from provider appeals or disputes.
Provider Dispute — A written communication to PA Health and Wellness, made by a Provider, expressing dissatisfaction with a PA Health and 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 and Wellness requires that all complaints received from providers be submitted to PA Health and Wellness in writing. PA Health and 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 and 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 and Wellness reviews the dispute to ensure that it has been filed within the required 30 days. If it has not, then PA Health and Wellness sends written notice to the provider that the dispute is not timely filed.
PA Health and 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 and Wellness CHC Provider Billing Manual (PDF) for the process for claims reconsideration and disputes. Claims status can be viewed via the PA Health and Wellness Secure Provider Portal. For claims status inquiries contact PA Health and 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 and Wellness.
- Contact a PA Health and Wellness Provider Service Representative: 1-844-626-6813
- Providers may discuss questions with PA Health and 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 and 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 and 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.