Asuris Agreement - Laserfiche WebLink

Home Browse Search

Provider Bllllng Dispute and Medical Necessity Procedure Determination Appeal Process Introduction A. Appllcabillty 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 or 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 Usted above. Note: The timeframe begins when the written request for refund Is sent to the Provider Failure to request review within the slated time period (absent a finding which, In our sole discretion, sets rorth acceptable extenuating circu mstances) will preclude the right to appeal and may Jeopardize the right to contest the decision In any fo,um. B. Process for Subml&&lon 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 ~ppeal form for Provider Billing Dispu te s and Medical Necesslty denials or a written descripl!on of the lssue(s) on the appeal must be submitted to Company, as further outlined on Compa ny's i:ro11ider web site . 3. The following lnfomiallon must be submitted with the Provider Adverse Determination Appeal form or the written description of the fssue(s) on appeal : (a) A detailed description of the disputed IHue(s); (b) The basis for disagreement with the decision : and (c) AR evidence and clinical documentation supporting your position. Asuris Standard MGA E•hlM O Dl •pute RasoluUon Process A188Hl864AA Pago 2 of9