Common use of Provider Claim Dispute Resolution Process Clause in Contracts

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 claim disputes not related to medical necessity, the MCO must provide an update to the provider every five business days beginning on the 15th business day until the claim dispute is resolved. When required, the written notice must include: The claim dispute tracking number; A summary of the pertinent facts and claim detail for claim related disputes; The specific statutory, regulatory, contractual, or policy references that support the resolution; and Next steps if the provider disagrees with the resolution, including the opportunity for external medical review if the claim denial was due to lack of medical necessity. Reprocess and pay disputed claims, when the resolution determines they were paid/denied incorrectly, within 30 calendar days of the written notice of the resolution unless a system fix is needed then additional time is allotted; and Automatically apply the corrective action or claims resolution to correctly adjudicate all other provider claims affected by the same issue.

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, MCO's provider portal), they do not include inquiries that come through ODM's ProviderWeb portal (HealthTrack). Provider claims disputes do not include provider disagreements with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity that are subject to external medical review as described in this appendix. 2. 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. 3. 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. 4. As a part of the provider claim dispute resolution process, the MCO must: Allow providers to file a written claim dispute within no later than 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 and 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 claim disputes not related to medical necessity, the MCO must provide an update to the provider every five business days beginning on the 15th business day until the claim dispute is resolved. When required, the written notice must include: The nature of the dispute; The claim dispute tracking number; A summary of the pertinent facts and claim detail for claim related disputes; The specific statutory, regulatory, contractual, or policy references that support the resolution; and Next steps if the provider disagrees with the resolution, including . If additional time to resolve a dispute is needed past 15 business days then the opportunity for external medical review if MCO must provide a status update to the claim denial was due to lack of medical necessity. provider every five business days beginning on the 15th business day until the dispute is resolved; Reprocess and pay disputed claims, when the resolution determines they were paid/denied incorrectly, within 30 calendar days of the written notice of the resolution unless a system fix is needed then additional time is allotted; and Automatically apply the corrective action or claims resolution to correctly adjudicate all other provider claims affected by the same issue.