Provider Administrative Claim Appeals
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Governs the process providers must follow to submit written administrative claim appeals to WellSense Health Plan to dispute denials or insufficient payments for administrative reasons; affects contracted and non-contracted providers serving impacted products listed.
No material clinical or coverage changes in this revision.
Key Definitions
Appeal Scope and Documentation Requirements
In-scope and out-of-scope appeal issues
Appeal types considered IN-SCOPE for provider administrative claim appeals and claim issues that are OUT-OF-SCOPE (must be routed elsewhere).
ALL of the following
IN SCOPE - provider administrative claim appeal types
- Level of Compensation/Reimbursement
- Timely Filing of Claims
- Retroactive Eligibility
- Lack of Prior Authorization/Inpatient Notification Denials
- Non-Covered and/or Unlisted Code Denials
- Other Party Liability (OPL)/Third Party Liability (TPL)/Coordination of Benefits (COB)
- Provider Audit and Special Investigation Unit (SIU) Appeals
- Duplicate Claim Appeals
OUT OF SCOPE - claim issues to route to other departments
- Claim Adjustments
- Corrected Claims
- Claim Resubmissions
- Claims Involving OPL/TPL/COB (providers are responsible for sending requests to the appropriate address/method)
Documentation and evidence requirements by appeal type
Documentation and data elements required for appeals, plus evidence/examples required for specific appeal types.
ALL of the following
General documentation requirements
- Completed Universal Request for Claim Review Form (legible)
- Written narrative explaining discrepancy and rationale
- Copy of the claim(s) in question and remittance advice (RA)
- Applicable OPL/TPL/COB documents (e.g., EOB from another carrier, PIP letter)
- All necessary clinical and administrative documentation
- No additional information accepted after a decision has been rendered
Required fields on Request for Claim Review Form
- Provider name
- MA-assigned provider identification (ID) number / NPI
- Contact name
- Contact telephone number
- Member name
- Member ID number
- Claim number
- Date of service
- Procedure code being appealed
- Charge amount
- Total claim charges
- Denial code
Level of compensation / reimbursement evidence
- Written narrative explaining requested changes
- Remittance advice identifying the claim to review
- Supporting documentation (invoices, operative/office notes, medical records)
Timely filing evidence
- Letter documenting reasons for late submission if beyond provider control
- Proof the member or another payer was billed within the applicable timely filing limit
- Acceptable proofs: provider billing date, RA from other insurer, PIP letter, Worker's Compensation denial
Retroactive eligibility evidence
- Typed letter of medical necessity
- Copy of the claim/RA
- All clinical and administrative documentation
- Proof of eligibility on DOS or evidence that eligibility was added retroactively (e.g., EVS printout)
Lack of prior authorization / inpatient notification evidence
- Typed member- and service-specific narrative explaining extenuating circumstances
- Copy of the claim/RA
- All clinical and administrative documentation pertaining to the service(s) or admission
- For untimely inpatient notification appeals, proof of successful fax transmittal to the Plan or proof notification was sent to another insurer (e.g., face sheet with dates/times)
Non-covered code and clinical code edit evidence
- Typed letter of medical necessity
- Copy of the claim/RA
- All clinical and administrative documentation
These appeals are forwarded to the Medical Claims Auditor for review and coordination.
Provider appeal processing and documentation criteria
Required documentation and Plan processing rules for different appeal types, and the workflow for review and decision-making.
ALL of the following
Universal requirements for all appeals
- All appeals must include a typed narrative where applicable, a copy of the claim/RA, and all clinical and administrative documentation.
Lack of prior authorization / inpatient notification processing
- Appeals must include a member- and service-specific typed narrative explaining extenuating circumstances that prevented prior authorization or timely inpatient notification.
- Untimely notification appeals must include proof of successful fax transmittal to the Plan or proof notification was sent to another insurer.
Non-covered code and clinical edit processing
- Non-covered code and clinical code edit appeals are forwarded to the Medical Claims Auditor for review and coordination with the appropriate Plan department.
- Submissions must include a typed letter of medical necessity, claim copy, and supporting documentation.
OPL/TPL/COB processing
- If the Plan is secondary, providers must exhaust primary carrier appeals before appealing to the Plan and include documentation of that exhaustion.
- Appeals must include claim copy, typed letter of medical necessity, and all supporting clinical and administrative documentation.
Process timing and dismissal rules
- The Plan provides one level of review for appeals submitted with all necessary information within 30 calendar days from the date the appeal is received at the Plan.
- Appeals submitted without required information will be dismissed; resubmissions must meet original appeal timeframes or may be denied as untimely.
Medical necessity review workflow
- PACs forward appeals requiring clinical criteria to the Claims Review Nurse who applies appropriate clinical criteria.
- If criteria are met the Claims Review Nurse approves the appeal as medically necessary; if not, the appeal is forwarded to a Plan Physician Reviewer, MD, for final determination.
Plan responsibilities and record retention
- The Plan is responsible for managing the appeals process, maintaining records, ensuring timely review, notifying providers of outcomes, and reviewing/updating policy annually.
- Provider administrative records are retained for no shorter than ten (10) years.
Monitoring and compliance records
- The Plan maintains records including: appeal type, provider name, date received, member name and ID, supporting information, appeal outcome, date of decision, actions taken, and decision maker credentials.
Claim Identifiers, Edits, and Timely Filing
| Denial code | Appeal form must include the denial code associated with the claim being appealed. |
| Procedure code | Procedure code being appealed must be present on the Request for Claim Review Form. |
| Non-covered codes and clinical code edits reviewed by Medical Claims Auditor |
Submission, Requirements, and Special-case Procedures
Submission methods and mailing address
Submit provider administrative claim appeals via the HealthTrio Provider Portal or by mail to WellSense Health Plan, Attn: Provider Administrative Claim Appeals, P.O. Box 55282, Boston, MA 02205. Paper appeals must include a completed Universal Request for Claim Review Form available on the Plan website.
- HealthTrio Provider Portal submission is accepted.
- Mail address: WellSense Health Plan, Attn: Provider Administrative Claim Appeals, P.O. Box 55282, Boston, MA 02205.
- Paper appeals must include a completed Universal Request for Claim Review Form (available at wellsense.org/providers/ma/documents-andforms#docs-8).
Timely filing limits and consequences
Appeals must be received by the Plan within product-specific timely filing limits: MCO/ACO and SCO appeals — 150 calendar days from the original denial date and no later than 300 calendar days from the date of service; Qualified Health Plans (QHP) — 90 calendar days from the original denial date and no later than 180 calendar days from the date of service. Provider Appeals received after these timeframes will be dismissed as untimely.
- MCO/ACO and SCO: 150 days from denial; absolute limit 300 days from DOS.
- QHP: 90 days from denial; absolute limit 180 days from DOS.
Form completeness, legibility, and dismissal rules
Universal Request for Claim Review Forms must be completed and legible; incomplete or illegible forms or appeals lacking the required written narrative will be dismissed. If dismissed, the Plan will notify the submitting provider and the provider may resubmit with a completed form, but the resubmission must be received within the original appeal timely filing timeframes or it will be denied as untimely.
- A completed form includes all required fields (including those marked with an asterisk) and the correct Review Type box; if 'Other' is used, specific information must be provided.
- Appeals that do not contain a written narrative detailing the request and rationale will be dismissed as unable to process.
- Resubmitted completed forms set the effective date of receipt to the date the Plan receives the resubmission; resubmissions not received within original timeframes will be denied as untimely.
Narrative and evidence required for lack of prior authorization/inpatient notification appeals
For Lack of Prior Authorization/Inpatient Notification appeals include a member- and service-specific typed narrative explaining extenuating circumstances, a copy of the claim/RA, and all clinical and administrative documentation; untimely admission notification appeals must also include proof of successful fax transmittal to the Plan or proof that notification was sent to another insurer.
- Typed, member- and service-specific explanation of why prior authorization or timely notification did not occur.
- Copy of the claim at issue and remittance advice.
- All clinical and administrative documentation related to the service(s) or inpatient admission/stay.
- For untimely admission notifications: proof of fax transmittal to the Plan or evidence notification was sent to another insurer (e.g., face sheet with dates/times and receipt from other insurer).
OPL/TPL/COB appeals — primary carrier exhaustion and required docs
OPL/TPL/COB appeals require exhaustion of the primary carrier's appeals process before appealing to the Plan and must include documentation of that exhausted appeal, a copy of the claim/RA, a typed letter of medical necessity, and all supporting clinical and administrative documentation.
- Exhaust primary carrier appeals first when the Plan is secondary.
- Include documentation proving the primary insurer appeal(s) were exhausted.
- Include a copy of the claim at issue (e.g., RA) and a typed letter of medical necessity.
- Provide all clinical and administrative documentation pertaining to the issue.
Provider Audit and SIU appeals — submission address and contents
Provider Audit and Special Investigation (SIU) appeals must be sent to the attention of the Director of Provider Audit and Special Investigations and include a typed letter detailing the discrepancy, a copy of the claim/RA, and all clinical and administrative documentation.
- Address appeals for final Provider Audit and SIU findings to the Director of Provider Audit and Special Investigations.
- Include a typed letter explaining in full detail the discrepancy or rationale for the appeal.
- Include a copy of the claim at issue (e.g., RA) and all supporting clinical and administrative documentation.
Non-covered code and clinical edit appeals — routing and required documentation
Non-covered code denials and clinical code edit appeals are forwarded to the Plan's Medical Claims Auditor and must include a typed letter of medical necessity, a copy of the claim/RA, and all clinical and administrative documentation.
- Appeals will be reviewed by the Medical Claims Auditor and coordinated with the appropriate Plan department for final determination.
- Include a typed letter of medical necessity explaining why the service(s) were necessary.
- Include a copy of the claim at issue (e.g., RA) and all supporting documentation.
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