July 12, 2019
Under California’s unfair payment practices law, payors are required to establish a fast, fair and cost-effective dispute resolution mechanism (i.e., “appeal process”) to resolve provider disputes. Anytime a payor contests, adjusts or denies a claim, they are required to advise the physician of the availability of the appeal process and instructions for submitting the appeal.
Payors are also required to acknowledge receipt of a written appeal within two working days for electronic appeals or 15 working days for paper appeals. The payor is required to respond to written appeals submitted by providers within 45 working days of receipt, and they must report to the Department of Managed Health Care, on an annual basis, the nature and volume of appeals received.
The California Medical Association (CMA) recommends the following to ensure your appeal is addressed properly by the payor:
- Clearly state in the subject line and first sentence of your letter that this is an “appeal.” Steer clear of the word “inquiry” in your appeal. Use of the word “appeal” leaves no doubt about your intention – to appeal the payment (or non-payment) of the claim – and will ensure the appeal gets to the right department and will be responded to in writing within the required timeframes.
- Make sure you are sending your written appeal to the correct address. Some payors, such as Blue Shield, have a different P.O. Box for claims vs. appeals. If you send your written appeal to the claims address, it will likely be processed as an “inquiry” and not an appeal, which means you may not receive a written response, let alone the desired outcome of reprocessing of your claim. If you are unsure of the appeals address, CMA’s Center for Economic Services publishes updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, UnitedHealthcare, Medicare/Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical directors, provider relations, appeals and other key contacts.
- Clearly state your “ask,” ideally at the beginning and the end of your letter. For example, are you asking that the bundling edits be re-reviewed, are you asking for a medical necessity appeal to be reviewed by a physician of same or like specialty, or are you disputing the payor’s claim that the patient wasn’t eligible? Simply venting about your frustration with how a claim was denied incorrectly or underpaid isn’t enough to communicate why you believe the claim was processed incorrectly or what action you are requesting in your appeal.
- Look out for the written acknowledgement of receipt of your appeal from the payor within 15 working days of the day you would expect the payor to have received it. Remember that sending your appeal certified mail will help confirm receipt of your appeal by the payor. If you don’t receive the acknowledgement of receipt, there is likely a problem and a phone call to the payor may be in order.
- Look out for the payor’s written response to your appeal that should include the pertinent facts and reasons for its determination, which should arrive within 45 working days of receipt of the appeal.
For more information regarding provider appeals, see CMA’s "Know Your Rights: Quick Guide for Appeals", “Know Your Rights: Timeframes to Appeal” and CMA health law library document #7057, "Managed Care Contractual Protections." These documents are all available free to members.
Don’t forget that CMA members and their staff can also contact CMA’s practice management experts at (888) 401-5911 or firstname.lastname@example.org if you don’t receive the acknowledgement or written response from the payor, or if you feel the dispute process has failed. We are here to help!