Policy No. 5-20 policies & procedures



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Policy No. 5-20

POLICIES & PROCEDURES

Section: National Claims Center

RE:

Claim Reconsideration Request

EFFECTIVE DATE:

May 2011




APPROVED BY:

TITLE:





DATE LAST REVISED:

Revised January 2012




COMMITTEE APPROVAL:

DAPR




Other





DATE:

December 2011









Purpose:

To define procedures used in the Claim Reconsideration Request process.



Policy:

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).


Upon receipt of the request, the NCC will:


  • 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.

If after review it is determined that no change will occur to the original claim, the following will occur:




  • 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.

Mail address: Send all Claim Reconsideration requests to

CareCentrix

Claim Reconsideration

111 Founders Plaza, Suite 801

East Hartford, CT 06108
No new claims should be submitted with this form. Please submit a separate form for each claim.
Patient Information

Name

DOB

Intake ID

Address: Street

State

Zip Code


Provider Information

Name

TIN

NPI

Address: Street

State

Zip Code


Claim Information

Provider Invoice Number

Service "From/To" Date

Original Amount Billed

HCPCS/CPT and Modifiers Billed

Original Amount Paid

Claim Number

Authorization Number(s)


Reason For Reconsideration Request

___ Claim denied for timely filing

___ Claim denied for Time In/Time Out or Oasis

___ Claim denied for primary payer's payment/denial information

___ Resubmission of a corrected claim (explain correction below)

___ Claim underpaid

___ Other

Please be specific when completing the description of dispute and the expected outcome, including dollar amount if possible.

Comments:


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.



Contact Name:________________________________ Date:___________________


Policy 5-20 Claim Reconsideration Request Page

Revisions: Created May 2011, Revised January 2012



Approvals: DAPR December 2011

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