Provider Disputes or Appeals

TrueCare provides several opportunities for you to request review of claim or authorization denials. Actions available after a denial include:

Claim Disputes

If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information, you should submit a corrected claim through the claim submission process. You do not need to file a dispute. Refer to the Claims page or the Provider Manual for further information related to claims submission. If you have made reasonable attempts to correct a claim and you remain dissatisfied with the disposition, you may submit a claim dispute stating why you disagree.

Claim disputes:

• Must be submitted within 30 calendar days of the written determination of the claim.
• Must be submitted through the provider portal
• Must be completed before requesting a claim appeal

Appeals

All appeal requests and associated information are reviewed by clinicians not previously involved with the case.

Include the following required documentation:

• Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the member has completed, preliminary procedures already completed, and the reason service is being requested.
• Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes.
• If the service has already been provided, a copy of the original remittance advice and/or the denied claim.
• If filing an appeal on behalf of a member or for pre-service issues, the member’s written consent, which must be specific to the service being appealed, is only valid for that appeal and must be signed by the member. Please note: You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form to record this consent.

Claim Appeals

Providers must exhaust the claim dispute process as outlined above before filing a claim appeal.

Claim appeals must be submitted:

• Within 30 calendar days of the resolution of the dispute process
• Through the provider portal

Claims appeals filed without first submitting a dispute will not be processed.

State Administrative Hearing: If you are dissatisfied with the decision of the claim appeal, you may submit the matter to State Administrative Hearing. The hearing is conducted by the Division of Medicaid. You may file within 30 calendar days of the appeal decision.

Clinical Appeals

If you disagree with a clinical decision regarding medical necessity, we make it easy for you to be heard.

After receiving a letter from TrueCare denying coverage, a provider or member can submit a pre-service or post-service clinical appeal.

If you have not received an authorization denial from the TrueCare Utilization Management department for a service that requires a prior authorization, you must submit a retro-authorization request prior to filing a clinical appeal.

Expediting Clinical Appeals

TrueCare shall not take punitive action against a provider who requests or supports an expedited appeal on behalf of a member. If you feel that your patient’s life or health is at risk if a decision about care is not made in a timely manner, you may ask us to expedite a clinical appeal.

Notification of Resolution

TrueCare will decide whether to expedite an appeal within 72 hours, or two days. We will make reasonable efforts to provide prompt verbal notification to the member of the decision to expedite or not expedite the appeal; the attempt will be made by phone.

Expedited appeals will be resolved, and verbal notification will be made within 72 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. TrueCare will send written notification to both the provider and the member on the same business day of the decision.

Denied Expedited Appeals

If we decide not to expedite the clinical appeal, we will send written notification within two calendar days of receipt of the appeal to both the member and the provider. This notification will include the determination to process the appeal as a standard appeal and any additional appeal rights the member may have related to our decision. The appeal will be resolved within 30 calendar days from the date the appeal was received and follow the standard TrueCare appeal process.

Extending an Appeal

Members may verbally request that TrueCare extend the time frame to resolve any medical necessity appeal request up to 14 days. TrueCare may also request an extension. Members may verbally request that we extend the time frame to resolve any medical necessity appeal request up to 14 calendar days. We may also request an extension. TrueCare will provide a written notice for the extension.

State Fair Hearing

Members or authorized representatives may request a State Fair Hearing if they are dissatisfied with their appeal decisions. Providers may submit these requests on behalf of the member with written member consent. Requests must be submitted within 120 calendar days of the appeal decision and will be conducted by the Division of Medicaid.