Appeal processes for medical providers

Provider Billing Dispute and Medical Necessity/Investigational* Procedure Determination Appeal Process
External audit appeal process
Provider Contract Termination Appeals

The following definitions apply to medical provider appeals:

Adverse Determination: For purpose of the appeal process, means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of any of the following:

• Application of utilization review;
  
• Determination that a treatment is investigational;
  
• Determination that a treatment is not Medically Necessary; or
  Billing Dispute.

Appeal Record: Includes all information which was relied upon in making the payment determination; or was submitted, considered, or generated in the course of making the payment determination, whether or not such document, record, or other information was relied upon in making the payment determination; or demonstrates compliance with the Plan's Claims procedures, administrative processes and safeguards; or constitutes a statement of policy or guidance with respect to the payment determination.

Billing Dispute: A dispute with a provider arising from Covered Services provided to Plan members by such providers concerning:

• The Plan’s application of coding and payment rules and methodologies for fee for service claims (including bundling and downcoding)
  
• Application of a Current Procedural Terminology (CPT®) modifier, and/or other reassignment of a code) to patient specific factual situations, including the appropriate payment when two or more CPT Codes are billed together, or
  
• Whether a payment enhancing modifier is appropriate.

Claims: A Provider’s request for payment submitted in the usual course of business between the Provider and the Plan.

External Review: Review of a Billing Dispute Appeal or a Medical Necessity/Investigational Procedure Appeal submitted to the External Review Organization with which the Plan has contracted to review services by a provider in compliance with the terms of the Adverse Determination Appeal Process.

External Review Organization (“ERO”): An independent organization employing physicians and other medically qualified individuals or experts that acts as the decision maker for External Reviews, through an independent contractor relationship with the Plan.

Investigational: The definition included in the member’s benefit contract/summary of benefits applies. To the extent that the member’s benefit contract/summary of benefits does not provide a definition of Investigational, the following definition shall apply: Treatment or procedure unsupported by reasonable and substantive scientific evaluation, which effectiveness has not been established, or the procedure or treatment has not been accepted and generally used by the medical provider community for a period of five (5) years.

Medically Necessary: Health care services that a physician, other health care professional or facility exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that are:

1. In accordance with generally accepted standards of medical practice.
   
2. Clinically appropriate, in terms of type, frequency, extent, site and duration and considered effective for the patients illness, injury or disease.
   
3. Not primarily for the convenience of the patient, facility, physician or other health care professional, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.

Revised February 2011