Process for Purchaser Provider Appeals Sample Clauses

Process for Purchaser Provider Appeals. If Provider disputes a Purchaser’s payment, non-payment, partial payment, late payment or denial of a claim, Provider may request reconsideration of Purchaser’s action by filing a written appeal with the Purchaser’s Fiscal Department within sixty (60) calendar days of Purchaser’s initial payment/denial notice. The Fiscal Department will review claims for reconsideration when submitted by a Provider under this Contract. Provider appeals information can also be located on Purchaser’s website at: xxxx://xxx.xxxxxxxxxxxxxxx.xxx/providers/claim-appeal-rights/. Appeals from Providers must include the following characteristics: a. Appeals must be clearly marked as “appeal” and addressed to the fiscal supervisor. b. Appealed claims must be received within sixty (60) calendar days of the Provider Remittance Advice (PRA) or denial letter. c. Claims must have all the elements of a clean claim as outlined in this contract, including Provider’s name, member’s name, service description or code, date(s) of service, date of billing, date of rejection, and copy of PRA. d. Claims must include a written statement indicating why the denial is being appealed and should be reconsidered for payment. If more than one claim is being appealed each must have a reason statement or cover statement indicating that the reason for the appeal is the same for all resubmitted claims. e. Claims submitted as appeals will be reviewed by Purchaser one time only. f. Providers can further dispute an unpaid claim with DHS. Completed appeal requests should be mailed to the following address: Lakeland Care Claims Department X0000 Xxxxxxx Xxxxxxx Xxxxx Fond du Lac, WI 54937 All appeals should be clearly marked on the application letter as “appeal.” Purchaser will respond to the appeal within forty-five (45) calendar days from the date of receipt of the request for reconsideration/appeal. If Purchaser fails to respond within forty-five (45) calendar days, or if Provider is not satisfied with the Purchaser’s response, Provider may appeal and seek a final determination from DHS.
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