![]() ![]() When reviewing the appeal, CareFirst CHPMD will consider a full investigation of the substance of the appeal including any clinical aspects. CareFirst CHPMD will permit the provider the opportunity before and during the appeal process to examine the appeals case file including medical records and any other documents and records. CareFirst CHPMD will resolve an appeal in writing within 30 days of receipt.ĬareFirst CHPMD will provide a reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing. An appeal must be filed within 90 days of the date of the denial of payment.ĬareFirst CHPMD will acknowledge an appeal in writing within 5 business days of receipt. CareFirst Community Health Plan Maryland (CareFirst CHPMD) Provider Appeal ProcessĪ provider may appeal a decision by CareFirst CHPMD to deny or partially deny payment of services rendered. ![]() If a provider is not satisfied with the actions taken by CareFirst CHPMD in addressing the grievance, they may contact the State’s Complaint Resolution Unit at 1-800- 284-4510 for further action. All provider grievances are logged, categorized and on completion, are evaluated by the Appeals and Grievances Committee and the Quality Improvement Committee for patterns and/or trends. All grievances are responded to in writing acknowledged within 5 business days of receipt investigated by the department that is the subject of the grievance, and resolved within 30 calendar days of receipt. Grievances are accepted verbally or in writing by any CareFirst CHPMD staff person and then routed to the A&G Department. Grievances are managed by the CareFirst CHPMD Appeals and Grievances (A&G) Department. A CareFirst CHPMD provider may file a grievance at any time in writing or by calling any CareFirst CHPMD staff member. We recognize that we may not always be able to achieve this goal and want to hear from our providers when they are dissatisfied with an administrative process within CareFirst CHPMD. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.CareFirst Community Health Plan Maryland (CareFirst CHPMD) Provider Complaint ProcessĬareFirst CHPMD wants to have a positive working relationship with all of our health care providers. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. If during your Level 1 appeal ("reconsideration") your Medicare Advantage plan does not decide in your favor, it is required to forward your appeal to an independent outside entity for a Level 2 review. If your Medicare Advantage plan fails to meet the established deadlines, it is required to forward your appeal to an independent outside entity for a Level 2 review. Your plan does not meet the response deadline. Your Level 1 appeal ("reconsideration") will automatically be forwarded to Level 2 of the appeals process in the following instances: If you are receiving services in an inpatient hospital, skilled nursing facility, home health agency or comprehensive rehabilitation facility, you may request an immediate review by a Quality Improvement Organization, if you disagree with your Medicare Advantage plan's decision to discharge you or discontinue services. You or your physician may request an expedited reconsideration by your Medicare Advantage plan in situations where the standard reconsideration time frame might jeopardize your health, life, or ability to regain maximum function. Special Circumstances for Expedited Review 60 days if the decision involves a request for payment.30 days if the decision involves a request for a service.In most cases, your plan will notify you of its reconsideration decision within: When You Will Get a Response (i.e., "reconsideration decision") You may request reconsideration by your Medicare Advantage plan within 60 days of being notified by your Medicare Advantage plan of its initial decision to not pay for, not allow, or stop a service ("organization determination").At Level 1, your appeal is called a request for reconsideration.Your Medicare Advantage plan must inform you in writing on how to request an appeal.How to Request an Appeal (i.e., "request for reconsideration") You may contact your plan or consult your plan materials for detailed information about requesting an appeal and your appeal rights. If you are in a Medicare Advantage plan, you can appeal the plan's decision to not pay for, not allow, or stop a service that you think should be covered or provided. ![]()
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