Policies & Procedures
Appeals
Definitions
The following definitions apply to our provider appeal process:
Claim dispute: relates to issues regarding the claim adjudication process, i.e., processing error, etc.
UR dispute: relates to issues regarding decisions made during the pre-authorization, concurrent review or retrospective review process. The Provider Appeal Process applies to appeals received after the services have been rendered. (The member appeal process applies to those appeals related to pre-service or concurrent review.)
Reconsideration: a formal review of a previous claim payment decision
Level 1 Claim Appeal: a written request by a provider/hospital to change an adverse reconsideration decision
Level 2 Claim Appeal: a written request by a provider/hospital to change an adverse Level 1 Claim Appeal. This is the final level of review for claim disputes.
Level 1 Appeal: a written request by a provider/hospital to change an adverse initial UR decision
Level 2 Appeal: a written request by a provider/hospital to change a Level 1 Appeal decision.
Appeal Level Committee: a written request by a provider/hospital to change a Level 2 Appeal (UR decisions only). This is the final level of review for UR decisions.
The provider appeal process should be followed if a provider/hospital wishes to appeal a claim or UR decision. All requests must be made within 60 days of the notice of denial.
Claim Disputes
Reconsideration
If a provider/hospital would like to dispute a claim payment decision, they must either call our provider call unit at 800-440-5071 or submit the issue to be reconsidered in writing to: Provider Appeal Coordinator, Community Health Network Of Connecticut, 11 Fairfield Boulevard, Wallingford, CT 06492. This must be done within 60 days of the claim decision. We will review the files and make a decision within 60 days if no additional information is required or, if new information is necessary, within 60 days of when the additional information is received.
Upon our review, if the decision is in the provider’s/hospital’s favor we will reprocess the claim for those services affected by the decision. If the decision is not in the provider’s/hospital’s favor, we will issue a decision in writing with instructions on how to file a Level 1 Claim Appeal.
Level 1 Claim Appeal
A provider/hospital may request a Level 1 Appeal within 45 days of the denial decision. Upon receipt of the request, we will review the files and make a decision within 60 days. If additional information is needed, we will notify the provider/hospital within 60 days of our receipt of the additional requested information.
If the Level 1 Claim Appeal decision is in the provider’s/hospital’s favor we will reprocess the claim for those services affected by the decision. If the decision is not in the provider’s/hospital’s favor we will issue the decision in writing within 60 days of receipt of the appeal. The provider may request a Level 2 Claim Appeal. Instructions on how to request this final level of review will be provided in the letter.
Level 2 Claim Appeal (Final Review)
This is the final level of review for a claim dispute and is available to providers upon request. If a provider/hospital feels such a level is warranted, the appeal must be submitted in writing to the Provider Appeal Coordinator within 45 days of the Level 1 Claim Appeal decision. Members of the executive staff will review this final level of claim appeal. A decision will be made in writing within 30 days.
Utilization Review Disputes
Level 1 Appeal
A provider/hospital may request a Level 1 Appeal within 45 days of the denial decision. Upon receipt of the request, we will review the files and make a decision within 60 days. If additional information is needed, we will notify the provider/hospital within 60 days of our receipt of the additional requested information.
If the Level 1 Appeal decision is in the provider’s/hospital’s favor we will reprocess the claim for those services affected by the decision. If the decision is not in the provider’s/hospital’s favor we will issue the decision in writing within 60 days of receipt of the appeal. A provider may request a Level 2 Appeal. Instructions on how to file a Level 2 Appeal will be provided in the letter.
Level 2 Appeal
A provider may request a Level 2 Appeal within 45 calendar days from the date of the Level 1 Appeal decision.
A reviewer not associated with our Level 1 Appeal review will review the files. We will notify the provider of our decision in writing within 60 days of receipt of the appeal. If we need additional information, we will request the information and issue our decision within 60 days of receipt of the information.
If the Level 2 Appeal decision is in the provider’s/hospital’s favor we will reprocess the claim for those services affected by the decision. If the decision is not in the provider’s/hospital’s favor we will issue the decision in writing within 60 days of receipt of the appeal.
The provider may request a review by the Appeal Committee. Instructions on how to request a review by the Appeal Committee will be provided in the letter.
Appeal Level Committee
The appeal committee is an ad hoc multidisciplinary panel comprised of the Chief Medical Officer; Vice President, Health Services; Director, Care Management; Vice President, Operations; and Director, Claims.
If a provider/hospital feels such a level is warranted, the appeal must be submitted in writing to: Provider Appeal Coordinator, Community Health Network Of Connecticut, 11 Fairfield Boulevard, Wallingford, CT 06492 within 45 days of the appeal decision.
The files will be reviewed and a decision will be made in writing within 30 days. This is the final level of appeal for a UR dispute.
All appeals are logged and tracked to ensure timely resolution.
Questions
For questions, please call our provider call center at 800-440-5071 or our provider appeal coordinator at 800- 440-5071 ext 4148.
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