![]() Refer to Claim reconsideration and appeals process section in Chapter 10: Our claims process, for more information. A description of this process is in your Agreement. If you disagree with the outcome of the claim appeal, you may file for an arbitration proceeding. Clear rationale/reason for contesting the determination and an explanation why the claim should be paid or approved.Member’s name and health plan ID number.The 2-step process allows for a total of 12 months for timely submission, not 12 months for step 1 and 12 months for step 2.Īs the health care provider of service, you submit the dispute with the following information: You must submit your claim reconsideration and/or appeal to us within 12 months (or as required by law or your Agreement), from the date of the original EOB or denial. If you feel the situation is urgent, request an expedited appeal by phone, fax, or writing: If you disagree with claim payment issues, overpayment recoveries, pharmacy, medical management disputes, contractual issues or the outcome of your reconsideration review, send a letter requesting a review to: How to submit your reconsideration or appeal If you disagree with the outcome of the Claim Reconsideration, you may request a Claim Appeal (step 2). There is a 2-step process available for review of your concern. ![]() ![]() For states with applicable legislation, any request for dispute will follow the state-specific process. Claim reconsideration, appeals and disputesĬlaim reconsideration does not apply to some states based on applicable state legislation (e.g., Arizona, California, Colorado, New Jersey or Texas). If you disagree with our decision regarding a claim adjustment, you may appeal. If we find a claim was overpaid, payment is due within 30 calendar days. If you find a claim where you were overpaid, send us the overpayment within 30 calendar days. If you think your claim was processed incorrectly, call the number on the member’s ID card. For contracted health care providers who submit electronic claims and would like to receive electronic payments and statements, call Optum Financial Services Customer Service line at 1-87 or visit > Partners >.Submit paper claims to the address on the member’s ID card. For ASIC members, submit electronic claims using Payer ID number 81400. ![]()
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