Provider materials and tools

Request appeals or reconsiderations

Please remember to submit all the required materials or the medical record can not be reviewed. The cover letter or appeal form must be submitted within 30 days of the date on the notification. 

Appeals or reconsideration

To request an appeal or reconsideration, medical records must be accompanied with one of the following:

  • A detailed cover letter to include the items specified in the Provider Appeals form. The cover letter must identify why the medical records were sent as well as a clinical summary of the provider’s rebuttal with references to national criteria such as; Interqual and/or Milliman –or  
  • A complete and detailed Provider Appeals form (additional pages can be attached).

 

Inpatient Hospital Days Benefit Exhaustion Medical Necessity Reviews

Medical Records submitted for those aged 21 years and older for emergency services due to being over the inpatient hospital days benefit limit must be submitted as follows:

  • A cover letter that must state that the facility is requesting a review for days they deem they provided emergency services. The cover letter must also include the dates that the hospital is seeking reimbursement, as well as an explanation indicating that the absence of immediate medical attention on those days would result in the following:
    • Placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
    • Serious impairment to bodily functions.
    • Serious dysfunction of any bodily organ or part.
  • Medical Records should include the History and Physical, Discharge Summary, Physician’s Order and Progress Notes.  It is not necessary to send nurses’ notes or pages of medications that the member received in the hospital.