Provider alert: understanding claim payment disputes and appeals

When you encounter an outcome for a claim that you disagree with, we provide a structured process to address such disputes. Here is a streamlined overview of the care provider claim payment dispute and appeals process. This alert focuses on using Availity Essentials for submission for underpayments because it is the most secure and efficient method. Detailed information about other submission methods is available in the provider manual. Please note that providers are expected to follow the dispute and appeals process before contacting their provider relationship management representative. This process offers providers the contractually binding guarantee that the health plan will respond within a set time period.

Types of claim issues and disputes

Steps in the claim payment dispute process:

1. Claim payment reconsideration
   Your first step involves requesting a reconsideration to investigate the disputed claim outcome:
• Submit via Availity: Log in to the Provider Availity Essentials Payment Appeal Tool at https://Availity.com and upload supporting documentation.
• Other submission options: Requests can also be made in writing or verbally (via Provider Services at 800-901-0020).
• Timeline: Must be submitted within 365 days from the Explanation of Payment (EOP) date.
• Outcome: You will receive a determination letter within 30 days, extendable to 60 days if more information is needed.
2. Claim payment appeal
   If unsatisfied with the reconsideration outcome, proceed to the appeals step:
• Submit via Availity Essentials: Continue using the Availity Essentials application for fast tracking and documentation uploads.
• Written submissions: Alternatively, mail your appeal to HealthKeepers, Inc.; Payment Appeals Unit; P.O. Box 61599; Virginia Beach, VA 23466-1599.
• Timeline: Appeals must be filed within 15 months of the date of service or 180 days from the reconsideration decision notice.
• Outcome: Expect a decision within 60 days, extendable to 120 days if additional info is required.
3. Regulatory appeal
   If both internal steps are exhausted, you can escalate the issue to the Department of Medical Assistance Services (DMAS):
• Submission methods: Appeals can be submitted online at Appeals (dmas.virginia.gov), by mail, by email to appeals@dmas.virginia.gov, or by fax to 804-452-5454.
• Timeline: Must file within 30 days of receiving the final decision from HealthKeepers, Inc.

Required documentation

For both reconsiderations and appeals, be sure to include:

• Provider and member details (NPI, TIN, member ID, claim number.)
• Detailed information supporting your dispute.

Note: the following terms are not part of the claims dispute and appeal process:

• Claim inquiry: merely a question about a claim without requesting changes
• Claims correspondence: requests for additional information to finalize a claim (this information should be submitted through a corrected claim)
• Medical necessity appeals: preservice appeals for denied services, which precede claim submission

More Information

Additional detailed information about the disputes and appeals process can be found in the provider manual.

Contact and support

If you have any questions about this communication, call Provider Services at 800-901-0020.