To define procedures used in the Claim Reconsideration Request process.
When a provider is dissatisfied with the outcome of a claim, they may file a request to have the claim’s outcome reconsidered by filing a Claim Reconsideration Request Form. This form allows for review and corrections to occur before a formal appeal is opened. The Claim Reconsideration form and a copy of the claim in question must be received by CareCentrix within 45 days of the original claim’s Explanation of Payment (EOP).
Review the claim in question along with details provided on the Claim Reconsideration Form. If appropriate, an adjustment is made to the original claim.
Complete Claim and Provider notes are entered to document the specific reconsideration request and any changes or adjustments made to the claim. An Explanation of Payment (EOP) is generated to the provider.
The claim submitted with the Claim Reconsideration Request Form will be processed and denied.
Complete Claim and Provider Notes are entered to identify the claim as a Claim Reconsideration Request along with any related denial details. An EOP is generated to the provider detailing the claim’s denial.
If the provider is still dissatisfied with the claim’s outcome, they may file a formal appeal.
CareCentrix Claim Reconsideration Form Instructions: This form is to be completed by providers to request a claim reconsideration for members enrolled in a plan managed by CareCentrix.
___ Claim denied for primary payer's payment/denial information
___ Resubmission of a corrected claim (explain correction below)
___ Claim underpaid
Please be specific when completing the description of dispute and the expected outcome, including dollar amount if possible.
If, after you have received a response upon completion of the Claim Reconsideration process, you still do not agree with the outcome you may submit a formal appeal with the CareCentrix appeal form and a copy of the claim in question.