Claim Appeal Process. January /3/2015
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- Kelley Austin
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1 Claim Appeal Process January 2015
2 Agenda Welcome! Provider Relations Updates Claim Appeal Process Changes for 2015 Reminders
3 Provider Resources
4 Provider News Paper Claims Effective Feb. 1, 2015, KMAP will no longer accept paper claims from KanCare providers. Paper claims will be submitted directly to the MCOs. SHP & Benefits Manager addresses are listed in SHP Bulletin #045 (2014 Bulletin List) and in the KMAP Bulletin. Flu Vaccine Procedure Codes: We have three new codes for vaccinating our members against the flu. For details, see SHP Bulletin #048 (2014 Bulletin List)
5 Provider News HEDIS Quick Reference Guides New guides are now online at SunflowerHealthPlan.com. Provider Relations Reps will provide you large print-outs during office visits in HEDIS pocket flip-books are in the works. New Claims Submission Policies Effective Jan. 1, 2015, all Corrected Claims, and effective Feb. 1, all Paper Claims should be free of handwritten verbiage and submitted on standard red & white UB-04 or CMS 1500 claims forms along with original EOP. (SHP Bulletin #047)
6 Provider News Coming Soon! 2015 Provider Manual The new manual will be more user friendly and will have the Billing Manual incorporated into the general provider manual. Look for this publication in early February. Stay up to date on provider news by bookmarking the online Provider Bulletins listing and by signing up for our Alerts.
7 Claims Appeal Process Reconsideration: Providers must appeal in writing or by phone within 90 calendar days of the date of EOP or Determination Letter. Medical documentation will be reviewed. An updated EOP will serve as notification. No form is required. Claims Dispute: Providers must appeal in writing only using the Claims Dispute Form within 30 days (33 days if hardcopy mailed) from date on EOP or Determination letter received following Reconsideration. A letter will be sent for notification. Each claim must have its own form.
8 Claims Appeal Process Reconsiderations and Claims Disputes are mailed to: Sunflower Health Plan Reconsiderations <OR> Claim Disputes PO Box 4070 Farmington, MO If you disagree with the decision made in the dispute/appeal response from Sunflower, you may appeal to OAH and request a State Fair Hearing within 30 days (33 days if notice was mailed to you in hardcopy) of dispute/appeal response from Sunflower.
9 Claims Appeal - Reminders Sunflower will respond to Reconsideration or Claim Disputes within 30 days of receipt. You must exhaust the Reconsideration and Claims Dispute process before asking for a State Fair Hearing related to a claim payment issue. Members cannot file an appeal for a claim issue. You can NOT balance bill the member for a medical service. If you provide a service not covered by Medicaid, you must talk with the patient prior to the service, document the discussion as well as the expected charges and get their signature of consent before you can bill them for the service.
10 Claims Dispute Process Step of Provider Appeal Process Reconsideration Claim Dispute/Appeal Send Where Send What Deadline to Submit Call Customer Service: Mail: Sunflower or Specialty Partner address listed in EOP or letter Mail: Sunflower or Specialty Partner address listed in EOP or letter Claim number Reason for request Supporting documentation Other items requested Claim Dispute form found here: lan.com/forproviders/providerresources/forms/ or additional form provided with EOP or letter. Pharmacy disputes only use form found here: lan.com/files/2013/01/uss- MAC-Pricing-Inquiry-Form.pdf Within 90 calendar days from date of original EOP or Determination letter Within 30 calendar days from date on EOP or Determination letter received following Reconsideration (33 days if we mailed the notice to you) Expected Timeline for Response 30 business days Notification of Decision Revised or unrevised EOP for same claim number 30 business days Letter with determination You may only file for a State Fair hearing after you have completed the appeal process that includes both reconsideration and dispute/appeal filing with determinations received by Sunflower. If you disagree with the decision made in the dispute/appeal response, you may then appeal to the Office of Administrative Hearings and request a State Fair Hearing within 30 days of the dispute/appeal response. State Fair Hearing Office of Administrative Hearings (OAH) 1020 Kansas Avenue Topeka, KS Phone: Applicable forms found here: 30 days from date of the Claim Dispute/Appeal Determination letter (33 if we mailed it to you) for this claim *Note- Provider must exhaust Reconsideration and Claim Dispute prior to requesting Varies at discretion of OAH Written Communication from OAH
11 Claims Dispute Process Type of Service Medical, NF/LTC or HCBS Services High Resolution Imaging Behavioral Health Services Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) Vision Dental Pharmacy None Sunflower Specialty Partner National Imaging Associate, Inc. (NIA) Cenpatico Behavioral Health Cenpatico, Specialty Therapy and Rehabilitative Services (STRS) OptiCare Dental Health and Wellness (DHW) US Script (USS) *NOTE: This chart is only a guide; please use the notice of action/adverse determination letter for mailing address and information requested. Provider Appeals: Post Service or Claims Disputes *Requires information/forms included in Appeal section of the Provider Manual Sunflower Health Plan Attn: Reconsideration OR Claim Dispute PO Box 4070 Farmington, MO Sunflower Health Plan Attn: Reconsideration OR Claim Dispute PO Box 4070 Farmington, MO Cenpatico Attn: Appeals Coordinator Research Blvd., Suite 400 Austin, TX OR Fax to: Sunflower Health Plan Attn: Reconsideration OR Claim Dispute PO Box 4070 Farmington, MO OptiCare Attn: Claims Appeal Committee PO Box 7548 Rocky Mount, NC Dental Health & Wellness Attn: Appeals PO Box 1432 Milwaukee, WI [email protected] Fax: Include only form found at: Pricing-Inquiry-Form.pdf
12 Questions? Thank you!
Date Posted: Nov. 27, 2012. Overview:
Landon State Office Building Phone: 785-296-3981 900 SW Jackson Street, Room 900-N Fax: 785-296-4813 Topeka, KS 66612 www.kdheks.gov/hcf/ Robert Moser, MD, Secretary Kari Bruffett, Director Sam Brownback,
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