External Independent Review (EIR) intake form

Anthem has partnered with the Kentucky Department for Medicaid Services in order to create an External Independent Review (EIR) intake form. Providers will be required to use this form and submit to the MCO to request an external independent review effective October 1st. The form can be found at the following link: https://providernews.anthem.com/kentucky/files/5216

Using the Form:

• Please use this form for all EIR requests. Verbal EIR requests will not be considered.
• Written requests not on this form will not be considered.
• If you would like to submit an EIR request, please use this form after you have exhausted the MCO’s internal appeal process.
• An EIR must be submitted within 60 calendar days of the MCO final adverse determination. The 60 calendar day timeline begins with one of the following:
  • Date that the notice was received electronically, if received electronically;
  • Date that the notice was received via fax, per the date and time documented on the fax transmission, if the notice was faxed; or
  • Post mark date on the envelope containing the notice, if the notice was sent via postal mail. An additional three (3) days shall be added if the service is by mail.
  • Please do not use the claim EOB date to calculate timely filing
• Any category on the form that is marked with an asterisk must be complete for the form to be considered.
• Please be as specific as possible when stating your area of dispute or why you believe the MCO’s decision on appeal is erroneous. If you attach a document, please provide a specific explanation of its contents.
• Please do not submit duplicate requests for EIR.

Types of Cases Eligible for EIR:

• Service coverage requirements which include a claim involving:
  • Whether the given service is covered by the Medicaid program or
  • Whether the provider followed the MCO requirements for the covered service
• Claim payment determination: Meaning cases stemming from the dollar amount paid on a claim or denial of a claim.
• Medical necessity adverse benefit determination: Meaning a case stemming from an adverse medical necessity determination.

Types of Cases not Eligible for EIR:

The following submissions will not be considered.

• Cases where the form is not filled out in its entirety
  • Please note incomplete forms may be resubmitted within the timely filing period.
• Cases where MCO internal appeal rights have not been exhausted
• Cases where the timely filing period has passed.
• Claims that are part of a Special Investigations Unit (SIU) aka fraud, waste, or abuse investigation
• Medicare claims or denials
• Disputes based on reimbursement provisions or other provisions addressed in the proprietary agreement between the provider and the MCO

If you have any further questions, please reach out to your provider relations representative, or call provider services at 1-855-661-2028.