Reconsideration and Payment Appeals Process. A Corrected Claim is a resubmission of a claim with alterations made to the original claim.

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1 1 Recnsideratin and Payment Appeals Prcess Crrected Claim A Crrected Claim is a resubmissin f a claim with alteratins made t the riginal claim. Crrected claims shuld be mailed with the crrected claim bx selected n the Claims Recnsideratin & Crrected Claim frm. Fr Prfessinal Claims, the frm t use is the CMS 1500 frm. Prviders shuld cmplete Bx Number 22 which is used fr Medicaid Resubmissin and/r Original Reference Number. Examples f Crrected Claims: Crrected Prcedure Cde Crrected Mdifier Resubmitted with CLIA number NDC number When resubmitting a claim, the prvider must enter the apprpriate claim frequency cde in the left-hand side f the field. 7 Replacement f prir claim, 8 Vid/cancel f prir claim Fr Institutinal Claims the apprpriate frm is UB04 frm. Prviders shuld check Bx Number 4 which is Type f Bill. Examples f Crrected Claims: Crrected Prcedure Cde Crrected Mdifier Resubmitted with CLIA number When resubmitting a claim, enter the apprpriate claim frequency cde in the 3rd Psitin f the Type f Bill. 7 Replacement f prir claim, 8 Vid/cancel f prir claim) Crrected claims must be received within 180 days f the adjudicatin f the riginal claim/date f the EOP (r per the timely filing prvisins in prvider's cntract). Crrected claims shuld be mailed t:

2 2 Recnsideratin and Payment Appeals Prcess INTtal Health PO Bx 5448 Richmnd, VA T file a crrected claim electrnically, please use apprpriate clearing huse: Emden (payer 10262) Gateway (payer IHP01) Capari (payer IHP01) Availity (payer IHP001-prfessinal claims nly) Availity (payer IHP002-facility claims nly) Fr additinal assistance, please call ur Prvider Services Department at , 8 am t 6 pm, Mnday thrugh Friday, ET. Recnsideratin A Recnsideratin is a claim resubmissin frm the prvider abut a disagreement with the manner in which a claim was prcessed, but des nt require a claim t be crrected. Examples f Recnsideratins: Previusly denied fr timely filing with attached justificatin Previusly paid, hwever disputing reimbursement Previusly denied fr n authrizatin, and ne nw exists Nte: A request t review a finalized claim denied as nt medically necessary r experimental/investigatinal shuld be submitted as a written medical necessity appeals. Recnsideratins must be submitted within 180 days (r within the cntractual timely filing) after the adjudicatin date/date n the EOP. INTtal Health will respnd t all recnsideratins requests within 30 calendar days.

3 3 Recnsideratin and Payment Appeals Prcess Verbal Recnsideratins: T submit a verbal recnsideratin, call the Claims Custmer Service Department at , 8 am t 6 pm, Mnday thrugh Friday, ET. Written Recnsideratins: T submit a written recnsideratin, use the Claims Recnsideratin & Crrected Claim frm, which is available nline at Select Fr prviders Prvider Resurces & Dcuments Frms Claims Recnsideratin & Crrected Claim Frm Cmplete the frm and select the apprpriate bx, attach any necessary infrmatin/dcumentatin and mail it t the address belw: INTtal Health PO Bx 5448 Richmnd, VA T file a recnsideratin electrnically, please use apprpriate clearing huse: Emden (payer 10262) Gateway (payer IHP01) Capari (payer IHP01) Availity (payer IHP001-prfessinal claims nly) Availity (payer IHP002-facility claims nly) Fr additinal assistance, please call ur Prvider Services Department at , 8 am t 6 pm, Mnday thrugh Friday, ET. First Level Payment Appeal Prvider dissatisfactin with a claim payment fr services prvided that is nt due t Preauthrizatin f services denied based n medical necessity. Claim payment (administrative) denial fr: Past timely filing

4 4 Recnsideratin and Payment Appeals Prcess Failure t request pre-authrizatin befre rendering service Incrrect billing Cntractual terms If the decisin is t adjust the claim t allw full reimbursement, we will infrm yu via an adjusted EOP. If the decisin is t partially adjust the claim r uphld the previus decisin, INTtal Health will mail yu a payment appeal determinatin letter, and an adjusted EOP. If yu are dissatisfied with the 1 st level payment appeal reslutin, yu may file a 2 nd level payment appeal. A Prvider Payment Appeal must be received within 90 calendar days f the date f the EOP, alng with the apprpriate Prvider Payment Appeal frm. INTtal Health will respnd t all claims payment appeals in 30 calendar days. 1 st level Payment Appeals shuld be mailed t: INTtal Health Attn: Recnsideratin & Payment Appeals Department PO Bx 5448 Richmnd, VA st level payment appeals will be reviewed by the IRU (Internal Reslutin Unit) and a letter with the final decisin will be mailed t the prvider. Secnd Level Payment Appeal If yu are dissatisfied with the 1 st level payment appeal reslutin, yu may file a 2 nd level payment appeal. Please include any additinal infrmatin that wuld supprt payment alng with the Prvider Payment Appeal frm. An appeal request must be received within 30 calendar days f the date n the 1 st level determinatin letter. INTtal Health will respnd t all claims payment appeals in 30 calendar days.

5 5 Recnsideratin and Payment Appeals Prcess 2nd level Payment Appeals shuld be mailed t: INTtal Health Attn: Recnsideratin & Payment Appeals Department PO Bx 5448 Richmnd, VA The Payment Appeals Cmmittee will review a 2nd level payment appeal and render a decisin DMAS If yu disagree with INTtal Health s final determinatin, yu may appeal this decisin t DMAS in writing within 30 days f the date f the final (2 nd level payment appeal) determinatin letter. Nte: Befre appealing t DMAS, yu must first exhaust all steps f INTtal Health s payment appeal prcesses. T request an appeal, submit yur written request t: Appeals Divisin Department f Medical Assistance Services 600 East Brad Street, Suite 1300 Richmnd, VA Upn receipt f ntificatin f a dispute by DMAS, INTtal Health will prepare and submit appeal summaries t DMAS Appeals Divisin, the DMAS cntact Mnitr, and the prvider invlved in the payment appeal. INTtal Health will attend all appeal hearings r cnferences, whether infrmal r frmal r whether in persn r by telephne, r as deemed necessary by the DMAS Appeals Divisin.