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Understanding the provider medical necessity appeals process for CT commercial members

07/08/2017

Here’s a refresher for your office, should you disagree with a decision we make to deny payment for an admission, service or procedure, or decide against extending an already authorized inpatient stay. In those instances, you can go through our one-level provider medical necessity appeal process.

Here are the following circumstances that an in-network provider may request a medical necessity appeal:

  • urgent/emergent situation — the patient’s condition was such that there was insufficient time to obtain preauthorization
  • the member did not provide correct insurance information to the provider
  • ConnectiCare did not provide correct information to the provider
  • if allowed in the Provider Contract language 

A provider may file an appeal to ConnectiCare verbally, in person, in writing or electronically (by fax or by email). But remember, an appeal needs to be initiated no later than 180 calendar days after we made the initial decision or when the claim was denied, whichever comes first.

When we receive an appeal, we will send it to an Independent Review Organization (IRO) for review by physician specialists who are:

  • in the same or similar specialty as the physicians that would typically provide treatment;
  • not involved in the initial adverse benefit determination; and,
  • not a subordinate of any person involved in the initial adverse benefit determination. 

A provider will receive written notification of the appeal decision according to regulatory time frames:

  • 30 days for pre- and post-service appeals
  • 45 days if additional information is needed 

If the IRO overturns our decision, we will provide coverage or payment based on the IRO’s determination.