What are my appeal rights for claims that were denied for administrative reasons (for example, timely filing)?

Please review the appeal rights listed on your Explanation of Benefits. Additional information is located on the provider web site in the Provider Operations Manual

What are my appeal rights for claims that were denied as a result of a clinical review?

Please refer to the submission response that you received notifying you of the clinical denial. This response contains instructions on appeal options.

How many levels of appeal are there?

For claims denied administratively (for example, timely filing) there is one level of appeal, except for states where regulatory requirements establish a different process. For claims denied as a result of a clinical review, there may be multiple levels of appeal, depending on state and federal regulations. Please review the appeal rights listed on your Explanation of Benefits and/or Submission Response.

What if the Credentialing Committee denies my initial application for participation or my recredentialing application?

Depending on the reasons why the committee made that decision, you may be offered the opportunity to submit additional information and/or submit an appeal. Your denial or termination letter explains your rights and the timelines you must follow.