Medicare - Medical Management Programs |
Provider Appeals
|
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 notice of adverse determination, delivered to the member.
|
Provider appeals are those where the provider 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 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:
Provider Appeals Department
ConnectiCare
175 Scott Swamp Road
Farmington, CT 06032-3124
Medical Appeals
(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 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:
ConnectiCare
P.O. Box 4061
Farmington, CT 06034-4061
If the denial is upheld on appeal, the final adverse determination notice shall include the reason for the determination and clinical rationale, and notice of availability of clinical review criteria referenced in the decision.
