If it is determined that an error was made when the claim was originally processed, the claim is reprocessed and a new explanation of payment issued.
If it is determined that the claim was originally processed appropriately, a response is provided.
Should we require additional information from the provider to effectuate a decision, we may request this information by telephone, fax or letter or through the Provider Portal’s messaging system. A decision will be made within 60 calendar days of receipt of the additional information.
Providers who are not satisfied with the plan’s decision may request an appeal in writing to the appeals and grievances department.