Provider Disputes. Contractor’s Quality Management (“QM”) department is responsible for resolving Participating Provider disputes. Providers may contact the QM department by mail at [address] or by calling the Participating Provider Dispute Department at [insert number]. Contractor will accepts submitted Participating Provider disputes for claims that were submitted by the Participating Provider within one year of the original decision date. Contractor’s QM department will acknowledge receipt of a provider claim dispute within five (5) working days of receipt and resolve provider disputes within forty-five (45) days of receipt of all reasonably relevant information.
Provider Disputes. Highmark is implementing certain appeal and dispute processes and procedures for Participating Physicians. Upon adoption, such processes and procedures shall be described as needed in the Love Settlement Policies and made available to Participating Physician. If pursued by the Participating Physician, the parties agree any final determination made as a result of such processes and procedures shall be final and binding, and non-appealable, upon all parties to this Amendment. This provision does not apply to disputes and matters that are subject to any separate provider dispute processes and/or member complaint, appeal or grievance procedures not covered under the Love Settlement Agreement.
Provider Disputes. It is Provider's duty to submit to Company accurate invoices and supporting documentation reasonably necessary to substantiate the charges. Each Provider invoice is deemed accurate on the 61stday after Provider issues it. Nevertheless, Provider may, within sixty (60) days of the date each invoice is issued, submit a revised invoice. If Provider submits a revised invoice Company will remit payment according to the payment terms outlined in Section 4.2. With the exception of telecommunications toll charges, if Provider does not submit a revised invoice within 60 days of each invoice, Provider waives any discrepancy in the original inaccurate invoice.
Provider Disputes. Company’s internal provider dispute resolution mechanisms are more fully described in Company’s Policies. Company’s Member Appeal process for matters including utilization review and medical necessity provides under some circumstances for appeal by the Provider on the Member’s behalf, including appeal to an Independent Utilization Review Organization or Medicaid Fair Hearing. Matters determined by these bodies are conclusive upon the parties and not subject to further appeal, arbitration or litigation between the parties (unless otherwise provided for under state and federal law). Provider may file a payment dispute verbally or in writing direct to Aetna Better Health of New Jersey to resolve billing, payment and other administrative disputes for any reason including but not limited to: lost or incomplete claim forms or electronic submissions; requests for additional explanation as to services or treatment rendered by a health care provider; inappropriate or unapproved referrals initiated by the provider; or any other reason for billing disputes. Provider Payment Disputes do not include disputes related to medical necessity. Disputes must be filed on or before the 90th calendar day following Company’s determination which forms the basis of the dispute. Provider can file a verbal payment dispute with Aetna Better Health of New Jersey by calling Provider Services Department, or in writing. Provider may be requested to complete and submit a Dispute Form with any appropriate supporting documentation. The Dispute Form, is accessible on Company’s website, or upon request will be given to Provider via fax or by mail. Provider may file a formal grievance in regard to policies, procedures or any aspect of our Company’s administrative functions or other matters specified in Company’s Policies, either in writing or by telephone. An acknowledgement letter will be sent within three (3) business days summarizing the grievance and will include instruction on how to revise the grievance within the timeframe specified in the acknowledgement letter and withdraw a grievance at any time until Grievance Committee review. Aetna Better Health of New Jersey will resolve all provider grievances within forty-five (45) calendar days of receipt of the grievance and will notify the Provider of the resolution within ten (10) calendar days of the decision.
