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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: If authorization was denied pre-service or during concurrent review. 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.

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: HMO: 855-766-1456

 

HMO SNP: 866-330-9368

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

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)

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

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)

Appeal: If authorization was denied pre-service or during concurrent review. 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.

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: n/a

Email: n/a

 

Appeal (pre-service/concurrent denial)

Note: Always follow instructions in denial letter.

Ambetter from

PA Health & Wellness

Appeals Depart., 3rd floor

12515-8 Research Blvd, Suite 400

Austin, TX 78759

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: 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)

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

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.