Commercial - Medical Management Programs |
Provider Appeals
Provider appeals are those where the provider, rather than the
member, will be financially liable for the services rendered. Providers may
submit their appeals of a denial orally, electronically, by facsimile, or in
writing to ConnectiCare's Provider Appeals Department or Member Appeals
Department. The appeal must be made as soon as possible after the denial, but no
later than 180 days after the provider was notified of the denial. There are two
types of provider appeals:
Administrative Appeals
(i.e., denials that are based on failure to follow a ConnectiCare administrative requirement)
Administrative appeals will be reviewed and a decision will be
given within 90 calendar days of the appeal request. Send provider
administrative appeals to:
ConnectiCare Provider Appeals
175 Scott Swamp Road
Farmington, CT 06032
Phone: 1-800-828-3407
Fax: (860) 674-7035
Medical Appeals
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Providers may also appeal a medical necessity decision on behalf
of a member. Details about how to appeal on behalf of a member are provided with
the initial notification of denial. Additional details are also provided in the
Massachusetts and New York appendices.
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(i.e., those where the denial of payment is based on medical
necessity criteria)
Medical appeals will be decided within 30 calendar days of
receipt, unless additional information is required. In such cases, you will be
notified of the need for additional information within 7 calendar days, and a
decision will be made within 30 calendar days of our receipt of complete
information, but no later than 45 business days from receipt of the appeal.
For medical appeals, an independent, external physician of the
appropriate specialty, who was not previously involved in the case, will review
the appeal and make a recommendation to us regarding the final determination.
Provider appeals receive only one level of review. Send provider medical appeals
to:
Provider Appeals
P.O. Box 4061
Farmington, CT 06034-4061
Phone: 1-800-828-3407
Fax: (860) 674-2866 or 1-800-313-0089
If the denial is upheld on appeal, the final adverse determination
notice shall include the reason for the determination and clinical rationale;
general information on the external appeal process (if applicable), including
instructions on how to initiate an external appeal, as well as a copy of the
external appeal application; and notice of availability of clinical review
criteria referenced in the decision.
