Provider Claim Dispute Resolution Process. Provider claim disputes are any provider inquiries, complaints, or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim denial. While these disputes can come in through any avenue (e.g., provider call center, provider advocates, MCO's provider portal), they do not include inquiries that come through ODM's ProviderWeb portal (HealthTrack). The MCO must establish and maintain a provider claim dispute resolution process for its network and out-of-network providers to dispute adverse claims payment decisions made by the MCO. The MCO must ensure that staff who review, investigate, and resolve a claim dispute have the appropriate experience and knowledge for that type of dispute and have access to all needed information and systems. As a part of the provider claim dispute resolution process, the MCO must: Allow providers to file a claim dispute within 12 months from the date of service or 60 calendar days after the payment, denial, or partial denial of a timely claim submission, whichever is later; Allow providers to submit claim disputes verbally or in writing, including through the provider portal; Convert a verbal dispute to writing and include a tracking number for the provider; Within five business days of receipt of a dispute, notify the provider (verbally or in writing) that the dispute has been received; Thoroughly investigate each provider claim dispute using applicable statutory, regulatory, and contractual provisions, collecting all pertinent facts from all parties and applying the MCO's written policies and procedures; Resolve and provide written notice to the provider of the disposition of all claim disputes resulting from the MCO’s decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity within 30 business days of the receipt of the dispute. Resolve and provide written notice to the provider of the disposition of all claim disputes, except for claim disputes resulting from the MCO’s decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity, within 15 business days of receipt of the dispute. Written notice is not required if the claim dispute was resolved with an initial phone call or in-person contact. If additional time is needed to resolve a claim dispute beyond 15 business days, the MCO must provide a status update to the provider on the 15th business day from receiving the claim dispute. For cla...
Provider Claim Dispute Resolution Process. 1. Provider claim disputes are any provider inquiries, complaints, or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim denial. While these disputes can come in through any avenue (e.g., provider call center, provider advocates, OhioRISE Plan's provider portal), they do not include inquiries that come through ODM's Provider Web portal (Healthtrack). Provider claims disputes do not include provider disagreements with the OhioRISE Plan's decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity that are subject to external medical review (EMR) as described in this appendix.
Provider Claim Dispute Resolution Process. Provider claim disputes are any provider inquiries, complaints, or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim denial. While these disputes can come in through any avenue (e.g., provider call center, provider advocates, MCO's provider portal), they do not include inquiries that come through ODM's ProviderWeb portal (HealthTrack). The MCO must establish and maintain a provider claim dispute resolution process for its network and out-of-network providers to dispute adverse claims payment decisions made by the MCO. The MCO must ensure that staff who review, investigate, and resolve a claim dispute have the appropriate experience and knowledge for that type of dispute and have access to all needed information and systems. As a part of the provider claim dispute resolution process, the MCO must:
