Provider Contract Termination Appeals

Level One Appeal
Level Two Appeal
Additional Information

A contracted provider may initiate an appeal of a contract termination decision made by Regence through the Provider Contract Termination Appeal Process.

1.  Level One Appeal
To request a Level One Appeal, you must send a written request to the Credentialing Department, at the address listed below within thirty (30) business days of receipt of the termination notification.

Provider Contract Termination Appeal - Level One
Attention: Credentialing Department
P.O. Box 21267, M/S S-555
Seattle, WA  98111-3267

A request for an appeal regarding a contract termination must include, at a minimum:

• A detailed description of the disputed issue(s)
• The basis for your disagreement with the decision
• All evidence and documentation supporting your position
• (Exception: Please note that all documentation required to justify your billing, including, but not limited to, chart notes, to be present in your files at the time of an audit. Additions to file documentation or the production of files that were not made available to Regence at the time of an audit will not be considered in connection with an appeal involving adverse audit findings. We will, however, consider your explanation as to why the documentation was not present at the time of the audit.)
• Your requested outcome

Upon receipt of the Level One Appeal request, we will make our best efforts to send you an acknowledgement letter within fifteen (15) business days.

The Level One Appeal panel is comprised of the Regence Credentialing Committee, which includes employees and community-based providers. Voting members of the panel are limited to the community-based providers.

Level One Appeals meetings are held on a monthly basis. Your appeal will be scheduled for review at the next available Level One Appeal meeting, subject to the time your appeal request and any additional information are received and the volume of appeals being reviewed by the panel.

If additional information is requested, it must be submitted within fifteen (15) business days of the date of the written request for information, unless a written request for a reasonable extension of time is granted.

• If the information is not received on time, a decision will be made at the next Level One Appeal panel meeting, based on the limited information available.
• If the additional information is received on time, the new information will be taken into consideration at the next Level One Appeal panel meeting.

Information not submitted within the time limit will not be considered for the Level One Appeal, unless otherwise allowed by the Level One Appeal panel.

You will receive a written determination within thirty (30) business days of the Level One Appeal panel decision. 

The Level One Appeal decision is deemed final on the thirtieth (30th) business day after you receive it, unless a written request for a Level Two Appeal is received timely.

2.  Level Two Appeal – “In-Person Hearing”
If you are not satisfied with the results of the Level One Appeal, you may submit a written request to the Credentialing Department, at the address listed below, for a Level Two Appeal, “in-person hearing” no later than thirty (30) business days after your receipt of the Level One Appeal decision.

Provider Contract Termination Appeal - Level Two
Attention: Credentialing Department
P.O. Box 21267, M/S S-555
Seattle, WA  98111-3267

The Level Two Appeal panel is comprised of individuals affiliated with Regence that have not been directly involved in the Level One Appeal or the Credentialing Committee’s decision to terminate participation, and that have the appropriate level of knowledge or training to understand the issues presented. The Level Two Appeal panel must be comprised of at least three (3) voting members. The majority of the Level Two panel membership shall be physicians affiliated with Regence.

The request for a Level Two Appeal must identify in detail the following:

• All issues on which you request re-evaluation
• Information not previously submitted to the Level One Appeal panel, if any
• (Exception: We expect all documentation required to justify your billing, including, but not limited to, chart notes, to be present in your files at the time of an audit.  Additions to file documentation or the production of files that were not made available to Regence at the time of an audit will not be considered in connection with an appeal involving adverse audit findings. We will, however, consider your explanation as to why the documentation was not present at the time of the audit.)
• Your requested outcome

The hearing is generally completed within two (2) hours and will be scheduled for two (2) hours, unless you notify us when requesting your Level Two Appeal that additional time is needed. We will make our best efforts to accommodate reasonable requests for additional time, as long as we are notified when you request the Level Two Appeal.

Upon receipt of the Level Two Appeal request, we will make our best efforts to send you an acknowledgement letter within fifteen (15) business days, setting forth proposed times and dates for the Level Two Appeal hearing. We will make our best efforts to make the proposed times and dates within sixty (60) business days of the Company’s receipt of your Level Two Appeal request. You will have five (5) business days from your receipt of the acknowledgement letter to notify us of your preferred time and date for the Level Two Appeal hearing. If you fail to notify us of your preferred time and date for the Level Two Appeal hearing within five (5) business days of your receipt of the acknowledgement letter, the hearing will be set on one of the proposed times and dates.

Prior to the Level Two Appeal hearing, you will receive a “Notice of Hearing”. The “Notice of Hearing” will indicate the following:

• Date of the hearing
• Time of the hearing
• Location of the hearing
• Names of the members of the Level Two Appeal panel
• Reasons for the adverse action
• Names of witnesses who will testify on Regence’s behalf at the hearing
• Your rights at the hearing

At the hearing, you have the following rights:

• To have representation by an attorney or other person of your choice
• To have a court reporter make a record of the proceedings at an additional cost to you. Costs associated with the court reporter must be paid by you prior to receiving a copy of the transcript
• To call witnesses and to examine/cross-examine witnesses
• To present relevant evidence (as determined by the panel)
• To submit a written statement at the close of the hearing

Approximately thirty (30) calendar days before the scheduled date of the hearing, a Level Two Appeal binder will be sent to you or your representative. The binder will include, among other things, the documentation reviewed by the Credentialing Committee initially and at the Level One Appeal, as well as any documentation submitted by you. If you wish to submit additional information to further supplement the Level Two Appeal binder, this information, as well as a list of witnesses that you plan to call, examine, and cross examine at the hearing, must be received no later than fourteen (14) calendar days prior to the hearing date. Unless otherwise allowed by the Level Two Appeal panel, documentation and witnesses not submitted at least fourteen (14) calendar days prior to the hearing date will not be considered by the Level Two Appeal panel and should not be brought to the hearing for the panel’s consideration. The only exception is that you may submit a written statement at the close of the hearing.

If the Level Two Appeal binder is later supplemented with new or revised information prior to the hearing, you will receive copies of the new or revised material as soon as practicable before the scheduled date of the hearing. After the Level Two Appeal binder has been finalized, it will be forwarded to the Level Two Appeal panel for review prior to the hearing. Neither you nor Regence may supplement the binder within thirteen (13) calendar days prior to the hearing, unless a written request for an exception is approved by the Chair of the Level Two Appeal panel.

You should receive written notification of the Level Two Appeal decision within fifteen (15) business days of the hearing. If the Level Two Appeal panel cannot reach a decision within fifteen (15) business days, or if additional information is needed to reach a decision, you will be informed of any additional information needed and a new date by which the decision will be made.

Decisions of the Level Two Appeal panel related to contract terminations are deemed final. Once a decision has been made by the Level Two Appeal panel, you have completed the Provider Contract Termination Appeals process. If you are not satisfied with our decision after completing the Provider Contract Termination Appeal process and want to continue to dispute the issue(s), you must initiate the appropriate process(es) as outlined in your provider contract.

Contract terminations that meet the criteria for reportable terminations will be reported to the HIPDB or the NPDB after our decision has been deemed final either through exhaustion of the Provider Contract Termination Appeal process or through failure to submit a timely request for appeal. You may not “self-term” to avoid being reported to the HIPDB or the NPDB. 

Please note that when we report a provider to a data bank, it is most often due to the reasons set forth above. However, there are other reasons we may report a provider to a data bank. Please see the HIPDB and NPDB regulations for more information. Additional information can be found at www.npdb-hipdb.hrsa.gov/.

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Revised February 2011