Starting Q4 of 2022, claims will go through two different Prospective reviews.
Claims will be reviewed on the following concepts:
Prospective concepts will be implemented in phases so claims will process differently between insured groups.
Fully Insured and BlueCard: December 2022
Self-Funded: Q2 2023
Medicaid Expansion: Q2 2023
Providers will receive results of these reviews on their Electronic Remittance Advice (ERA). Search the Payment Integrity Denial Resolution information to aid in determining why the claim denied and next steps.
If a provider disagrees with a payment determination and a claim correction is not the next step, request a Reconsideration using the Appeal form.
A reconsideration is not an appeal as it’s a payment dispute and not an adverse benefit determination; it does not use the member’s appeal rights. A reconsideration of a payment determination is a provider right only. When completing the appeal form, select Provider on behalf of self.
Providers will receive a reconsideration notification within 45 days of receipt of the request. If a provider disagrees with the determination, they will have the option of requesting a second reconsideration within 45 days. Providers will receive a reconsideration notification of their subsequent request within 45 days of receipt of the request.