In an effort to enhance participating provider satisfaction and ensure efficient and timely reconsideration of claim payment /denial appeals, the Health Plan has developed the Claim Research Request Form, which a participating provider will need to utilize for a reconsideration of a previously paid or denied claim. Please make copies of the blank form as necessary and retain a copy of the completed forms for your records.
Completion of a Claim Research Request Form is necessary when requesting a reconsideration of a claim for any of the following reason(s):
- Request reconsideration of a procedure/service denial that was a result of the Health Plan’s claim editing software (denials will reflect an explanation code description of DENY-CLAIM EDIT).
- Request reconsideration of a claim payment or denial when a coordination of benefits adjustment is required.
- Request reconsideration of a claim denial when additional necessary medical documentation is being presented. (Such as miscellaneous code submissions)
- Request a retraction of a claim payment. (Such as an overpayment, duplicate claim payment or cancelled charge).
- Request reconsideration of an approved/paid service due to a data element correction (Such as member ID number, date of service, billed charge or number of units).
- Request reconsideration of an incorrect payment or denial.
Completion of a Claim Research Request Form is NOT necessary when requesting a reconsideration of a claim for the reasons listed below:
- Reconsideration of claim denied for no Primary Care Physician (PCP) Authorization (Referral). Specialty Care Provider can contact the applicable Customer Service Team.
- Reconsideration of a claim denied due to a provider billing error. (Such as missing or invalid Diagnosis, Procedure, Revenue, Modifier or Place of Service Codes. Missing or invalid Provider name or Tax Identification Number (TIN). These claims can be corrected by the provider and resubmitted via the provider's usual submission method. Corrections to member ID # or date of service require the use of the Claim Research Request Form.
- Requesting addition of a HCPCS code to the provider's existing payment schedule. Please contact your Provider Relations Representative.
Claim Research Request Forms and necessary accompanying documentation must be submitted within 60 days from the date of the Health Plan Explanation of Payment (EOP). Please remember to check off the applicable reason for the reconsideration request as well as including the name and phone number of the person completing the form. Any request submitted without the required documentation or after the 60-day submission period is not eligible for reconsideration and will be returned to your office.
Reconsiderations will be finalized in 45 days. The Provider will be notified of the Health Plan determination via:
- A new EOP with an explanation code indicating the decision; or
- A returned claim research request form with a brief explanation of the reconsideration denial.
Please contact your Provider Relations Representative with any questions regarding the claim research request form or these instructions.
