Appeals
Providers notified by MHP of claims
denial have the right to appeal the decision. A claims denial is a non-payment of a claim for reasons
such as, but not limited to, non-emergent, not medically necessary, denied authorization.
Providers who appeal the claims denial decision may do so as
follows:
All claim appeals must be submitted
within sixty (60) days of receipt of original claim rejection or from date of
denial of Level 1 appeal from Midwest Health Plan, Inc. All appeals must include a cover
letter indicating basis for appeal and the additional documentation supporting
the appeal. Resubmission of a denied
claim alone does not constitute an appeal.
It is the Policy of Midwest Health Plan,
Inc. (MHP) to allow Par and
Non-par providers to appeal any claim denials made by MHP. MHP wishes to resolve all disputes as
expeditiously and fairly as possible. There are two levels of claim appeal
within the Plan, Level 1 and Level 2, with Level 2 being the final decision. Any further appeals beyond Level 2 by
contracted providers must follow the Binding Arbitration Appeals Process or
Rapid Dispute Resolution. All
non-contracted providers who wish to pursue the denial further must go through
the Rapid Dispute Resolution with the State of Michigan.
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All appeals related
to claim denials are mailed to:
Midwest Health Plan
Attention: Claims Appeals Coordinator
5050 Schaefer Road
Dearborn, Michigan 48126
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Claims Appeals Coordinator or his/her
designee will date-stamp and log the
appeals into claims log, noting:
·
Provider Name
·
Date Appeal Received
·
Recipient ID Number
·
Member Name
·
Date of Service
·
Date Claim Originally Paid or Rejected
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If appeal is received
more than 60 days after date of original claim decision (unless extenuating
circumstances are demonstrated), a letter will be sent to the provider
indicating no action will be taken. The date the letter was sent will be noted
in log and copies of appeal and rejection letter kept on file.
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If appeal is within
the 60 day required timeframe, the Claims Appeals Coordinator will review
relevant claims history on system, noting claims transactions on the
documentation, including date claim paid or rejected, reason for rejection, type
of claim, any related claims, etc.
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Claims Appeals
Coordinator will review appeal documentation and determine nature of appeal,
whether appeal is medical or administrative in nature, and whether this is a
Level 1 or Level 2 appeal. A brief
synopsis of the appeal and indication of medical – level 1 or 2 versus
administrative – level 1 or 2 will be recorded in log.
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All Level 1 medical
appeals are to be forwarded to the Director of Health Services for review and
decision. The date the appeal was
forwarded to the Director of Health Services is noted in the log. All Level 2 medical appeals are to be
forwarded to the Medical Director for review and decision. The date the appeal was forwarded to the
Medical Director is noted in the log.
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All Level 1
administrative appeals are to be forwarded to the Claims Manager for review and
decision. The date the appeal was
forwarded to the Claims Manager is noted in the log. All Level 2 administrative appeals are to
be forwarded to the Sr. Director of Operations for review and decision. The date the appeal was forwarded to the
Sr. Director of Operations is noted in the log.
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All appeals must be
decided within 30 days of receipt. It is
the responsibility of the Claims Appeals Coordinator to assure timely decision
on appeals by the Director of Health Services, Medical Director, the Claims
Manager, and the Sr. Director of Operations,
as appropriate.
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The Director of
Health Services, Medical Director, Claims Manager, or the Sr. Director of
Operations will either Approve the appeal, which means that the claim will be
paid, or will Uphold the original decision, which means the appeal will denied
and no further action/payment will be made on the claim. The decision must be noted by the Director
of Health Services, Medical Director, Claims Manager and Sr. Director of
Operations on the appeal letter, along
with date, reason for denial, and signature.
The appeal letter is then returned to the Claims Appeals Coordinator.
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Upon receipt of
appeal decision, the Claims Appeals Coordinator will log the date received back
and the decision. If the original
decision is overturned and the service is approved, the claim will be forwarded to the claims
department for processing. A letter will
be sent to the Provider notifying them of the Approval and that payment will be
forthcoming within 2-3 weeks. If the
original decision is upheld, and the service is not approved, a letter will be
sent to the Provider notifying them of the appeal denial and the reason for the
denial. Further appeal steps, as
appropriate, will be noted in the letter.
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All appeal
correspondence and copies of any paid claims will be kept on file by the Claims
Appeals Coordinator.
BINDING ARBITRATION PROCEDURE
Upon receipt of an appeal by a provider
(par or non-par), Midwest will review the information. This review will be undertaken by the
Operations or Health Services Senior Staff.
This will be considered a Level 1 appeal.
If the provider is not satisfied with the decision reached on the Level 2
appeal, they may request a review by internal Account Receivable Reconciliation
Group (AARG). This request must be
submitted in writing within 60 days of receipt of the Level 2 decision.
Midwest Health Plan will attempt to
resolve all issues at the ARRG, both contracted and non contracted providers
have the right to request binding arbitration.
Midwest Health Plan will retain a list of
arbitration entities.
RAPID RESOLUTION PROCEDURE
Midwest Health Plan has developed an
internal Accounts Receivable Reconciliation Group (ARRG) to meet with contracted
and non contracted hospital providers who wish to achieve reconciliation
solutions for outstanding accounts.
The ARRG meets on an ongoing basis with contracted providers. If a non contracted provider has an
issue with outstanding accounts, Midwest will also encourage these providers to
attend the ARRG meetings. These
meetings occur quarterly, or more frequently if needed. The ARRG is made up of the Chief
Financial Officer and the Director of Operations from Midwest Health Plan, and
representatives from the hospitals.
The Midwest Health Plan Provider Services Representative assigned to the
hospital system with the issue may also be present at the ARRG meetings. Midwest Health Plan will attempt to
resolve all issues at the ARRG.
Where a disputed claim or group of
similar claims, remains, the hospital or Midwest Health Plan may submit a
request to Michigan Department of Community Health for Rapid Dispute Resolution
(RDRP).