Appeal Decision Issued by the Department Sample Clauses

Appeal Decision Issued by the Department a. The Department has 45 days from the receipt of all pertinent information to inform the provider and the FCMH of the final decision. b. If the Department’s decision is in favor of the provider, the FCMH will pay provider(s) within 45 days of receipt of the Department’s final determination. c. A reconsideration of a final decision will only be made if an error has been made or there was misrepresentation of facts. d. The Department will review the appeal documents and make a Final Decision based on the contract (both the DHS-FCMH contract and the FCMH-provider contract, if submitted, will be used to make the decision). e. The Department will not review decisions based on contractual requirements between the provider and FCMH, including appeals related to: i. Clinical level of care (e.g., observations vs. inpatient) provided to the member, or ii. Results of contractually agreed upon FCMH reviews of claims or medical records. 1. The FCMH must have adequate staff available to train and support providers on resources available in order to prevent claim processing issues and denials. Refer to Article XI, C(7). a. The FCMH must provide information to network providers of any FCMH-facilitated training opportunities which may reduce denied claims and provider appeals. b. Ensure that providers know, understand, and comply with all business standards regarding completion and submission of accurate, correct and timely claims. This includes correct coding and maintenance of medical record. x. Xxxxx providers access to all online technology and communication offered by the FCMH (i.e., not limited to claim and appeal submission, policy resources, FCMH website). Electronic notification from the FCMH constitutes receipt of information or claim action; it is not necessary to wait for paper notification of claim action. d. Encourage providers to access and use the ForwardHealth Portal, including online Handbooks and Provider Updates. 2. The FCMH must perform ongoing monitoring of provider appeal numbers and perform provider outreach and education/training on trends to prevent future denials/partial payments, thus reducing future provider appeals to the FCMH and to the Department.
Sample 1
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Related to Appeal Decision Issued by the Department

  • Department Review The parties shall resolve disputes through written submission of their dispute to the Department’s Contract Manager. The Department shall respond to the dispute in writing within ten (10) Business Days from the date that the Department’s Contract Manager receives the dispute. The Department’s decision shall be final unless a party provides the other party with written notice of the party’s disagreement with the decision within ten (10) Business Days from the date of the Department’s decision. If a party disagrees with the Department’s decision, the party may proceed to subsection (b) below.

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