Asuris and KCPHD Agreement - Laserfiche WebLink

Home Browse Search

Provider Appeals Provider Billing Dispute and Medical Necessity Procedure Determination Appeal Process Introduction A. Applicability The Company Provider Billing Dispute and Medical Necessity Procedure Determination Appeal Process (Adverse Determination Appeal Process) will apply when the Provider is at financial risk for the cost of the claim. The member appeal process will apply when the member is or may be at financial risk for the cost of the claim. For purposes of Billing Disputes only, the definition of Provider shall include providers who contract with Company as Participating Providers and non - contracted providers. Internal Review Process A. Time Period for Submission of an Adverse Determination Appeal by Provider An Adverse Determination Appeal must be submitted in writing within the following timeframes 1. For Washington Providers, within 24 months after payment of the claim or notice that the claim was denied or 30 months for claims subject to coordination of benefits. 2. If a Provider wishes to appeal a refund request initiated by Company, that Provider can submit an Adverse Determination Appeal within the same timeframe as other Adverse Determination Appeals as listed above. Note: The timeframe begins when the written request for refund is sent to the Provider Failure to request review within the stated time period (absent a finding which, in our sole discretion, sets forth acceptable extenuating circumstances) will preclude the right to appeal and may jeopardize the right to contest the decision in any forum. B. Process for Submission of an Adverse Determination Appeal 1. A Provider may use the Provider Adverse Determination Appeal form, which can be found on Company's Provider Web Site: www.asuris.com/provider 2. The appeal form for Provider Billing Disputes and Medical Necessity denials or a written description of the issue(s) on the appeal must be submitted to Company, as further outlined on Company's provider web site. 3. The following information must be submitted with the Provider Adverse Determination Appeal form or the written description of the issue(s) on appeal: (a) A detailed description of the disputed issue(s); (b) The basis for disagreement with the decision; and (c) All evidence and clinical documentation supporting your position. Asuris Standard MGA Exhibit D Dispute Resolution Process Al8816854AA Page 2 of 9