Appeal and Reconsideration Procedures
Community HealthChoices (CHC) Medicaid
Retrospective Authorization Review: Retrospective review is an initial review of services provided to a Participant, but for which authorization and/or timely notification to PA Health & Wellness was not obtained due to extenuating circumstances (i.e. Participant was unconscious at presentation, Participant did not have their Medicaid ID card, or otherwise indicated Medicaid coverage, services authorized by another payer who subsequently determined participant was not eligible at the time of service). Requests for retrospective review must be submitted promptly. A decision will be made within 30 calendar days following receipt of request, not to exceed 90 calendar days from date of service. Presumptive eligibility rules apply.
Medical Necessity Appeal: If authorization or retro-authorization was denied, in part or whole, follow the Appeal process.
Claim Reconsideration: Follow the claim reconsideration process if the claim did not pay as expected, but the claim does not need to be corrected. This can include a request to reconsider authorization denials if an authorization was required and not obtained (justification should be included).
| Process | Mailing Address | Notification Timeframe | Determination TAT | Fax/Phone/Email | Web Portal |
Pre-Service Authorization | n/a |
Scheduled Admission: 5 business days Elective OP: 5 business days Emergent IP: within 24 hours or next business day
Observation (≤23 hours): one business day for non-par Observation (>23 hours hours): IP auth within 1 business day ER and post stabilization, urgent care, crisis intervention: 2 business days Maternity admit: 1 business day with delivery outcome Newborn admit: 1 business day Neonatal ICU admit: 1 business day |
Urgent: 72 Hours Non-Urgent: 2 business days of receipt of all necessary info, not to exceed 14 calendar days | Fax: Follow fax submission directions located on the applicable form(s) Phone: n/a Email: n/a | Yes |
Concurrent Review Note: After initial auth, ongoing reviews are done via phone/fax | n/a | 1 business day | Fax: Submit ongoing records via fax/phone Phone: 844-626-6813 Email: n/a | No | |
Peer-to-Peer Note: PHW will make 3 attempts to schedule prior to closing/upholding; 2 call attempts by MD prior to closing/upholding | n/a | Request P2P within 2 business days of date of denial | P2P determination within 1 business day | Fax: n/a Phone: 844-626-6813 Email: n/a | No |
Retrospective Authorization Review Click for Authorization Request Forms Note: If request for Retro-Auth exceeds 90 days from DOS, please see "Claim Reconsideration" | n/a | Request within 90 calendar days from DOS. | Determination within 30 calendar days | Fax: Follow fax submission directions located on the applicable form(s) Phone: 844-626-6813 Email: n/a | Limited based on DOS |
Medical Necessity Appeal
Note: appeals must be filed within 60 days of the notice of determination. If there is a claim on file, please follow the process for Claim Reconsideration below. | PA Health and Wellness Attn: C&G Provider Appeal 1700 Bent Creek Blvd.
NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Determination within 30 calendar days of receipt | Fax: 844-873-7451 Phone: 844-626-6813 Email: PHWComplaints | No | |
Claim Reconsideration Click for PHW Claim Reconsideration Form Note: if auth/medical necessity denial related, with records attached, will be routed to UM | PA Health and Wellness Attn: Reconsideration PO Box 5070 Farmington, MO 63640 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | 365 days from date of service | 30 calendar days | Fax: n/a Phone: n/a Email: n/a | Yes |
Wellcare By Allwell Medicare (MAPD, D-SNP & PPO)
Appeal: An Appeal is the mechanism which allows Providers the right to appeal actions of Wellcare By Allwell such as a pre-service prior authorization denial. If authorization was denied pre-service or during concurrent review, follow appeal instructions on the notification letter. This process excludes post-service and claims-related disputes.
Claim Reconsideration: Follow the claim reconsideration process if you disagrees with the original claim outcome (payment amount, denial reason, etc.). The reconsideration process can be followed if an authorization was not obtained or if the member has been discharged/services already rendered. Submit claim along with supporting medical records/documentation and reason for late notification or lack of prior authorization, as appropriate.
Claim Dispute: Follow the claim dispute process if there is disagreement with the outcome of the Reconsideration process.
Retrospective Review: A retrospective review is any review of care or services that have already been provided to a Member and requires the submission of a claim. This includes acute hospital stays when initial notification is received after the Member has been discharged. The requestor must submit a claim for payment with supportive documentation as applicable (i.e. medical records to support clinical review, certificate of Medical Necessity, consent forms or invoices). If the claim is denied, the Provider will have the ability to file a claim reconsideration.
| Process | Mailing Address | Determination TAT | Fax/Phone/Email | Web Portal |
Pre-Service Authorization | n/a | See charts in the Wellcare by Allwell Provider Manual for determination timeframes | Fax: Follow fax submission directions located on the applicable form(s) Phone: HMO: 855-766-1456 HMO SNP: 866-330-9368 Email: n/a | Yes |
| Concurrent Authorization | n/a | Fax: Fax supporting clinical Phone: HMO: 855-766-1456
HMO SNP: 866-330-9368 Email: n/a | No | |
| Peer-to-Peer | n/a | Fax: n/a Phone: 1-833-456-8216 Email: n/a | No | |
Appeal (pre-service/concurrent denial) Note: Always follow instructions in denial letter. | Centene Corporation Attn: Grievances & Appeals Medicare Operations 7700 Forsyth Blvd. Saint Louis, MO 63105 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: 844-273-2671 Phone: HMO: 855-766-1456
HMO SNP: 866-330-9368 Email: n/a | No | |
| Claim Submission | Wellcare by Allwell Attn: Claims PO Box 3060 Farmington, MO 63640-3822 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: n/a Phone: n/a Email: n/a | Yes | |
Claim Reconsideration Note: Can be post-service or post-discharge with Medical Records if incorrect/no authorization obtained (include reason for not obtaining auth within required notification timeframe) If filing by mail, must use dedicated forms: | Wellcare by Allwell Attn: Request for Reconsideration PO Box 3060 Farmington, MO 63640-3822 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: n/a Phone: n/a Email: n/a | Yes | |
| Claim Dispute | Wellcare by Allwell Attn: Claim Dispute PO Box 4000 Farmington, MO 63640-4400 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: n/a Phone: n/a Email: n/a | No |
Ambetter Marketplace (Commercial Exchange)
Member Appeal: If authorization was denied pre-service or during concurrent review. This process excludes post-service and claims-related disputes. Pre-service Member Appeals must follow the Appeal process below. A member must designate in writing to Ambetter for a provider to act on behalf of the member regarding the appeal process.
Claim Reconsideration: A request for reconsideration is a communication from the provider about a disagreement with the manner in which a claim was processed. Generally, medical records are not required for a request for reconsideration. However, if the request for reconsideration is related to a code audit, code edit, or authorization denial, medical records must accompany the request for reconsideration. If the medical records are not received, the original denial will be upheld.
Claim Dispute: Follow the claim dispute process if there is disagreement with the outcome of the Reconsideration process.
| Process | Mailing Address | TAT | Fax/Phone/Email | Web Portal |
Pre-Service Authorization | n/a | See charts in the Ambetter Provider Manual for determination timeframes | Fax: Follow fax submission directions located on the applicable form(s) Phone: n/a Email: n/a | Yes |
| Concurrent Authorization | n/a | Fax: n/a Phone: n/a Email: n/a | ||
| Peer-to-Peer | n/a | Fax: n/a Phone: 1-833-456-7956 Email: n/a | ||
Member Appeal Note: A member must designate in writing to Ambetter for a provider to act on behalf of the member regarding the appeal process. Follow instructions in the authorization determination letter | Member appeals and appeals o nmembers' behalf: Ambetter from PA Health and Wellness Fax 1-833-886-7956 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: 833-886-7956 Phone: 833-510-4727 Email: n/a | No | |
| Claim Submission | Ambetter Attn: Claims PO Box 5010 Farmington, MO 63640 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: n/a Phone: 833-510-4727 Email: n/a | Yes | |
Claim Reconsideration Note: Generally, medical records are not required for a request for reconsideration. However, if the request for reconsideration is related to a code audit, code edit, or authorization denial, medical records must accompany the request for reconsideration. If the medical records are not received, the original denial will be upheld. | Ambetter Attn: Request for Reconsideration PO Box 5010 Farmington, MO 63640 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: n/a Phone: 833-510-4727 Email: n/a | Yes | |
| Claim Dispute | Ambetter Attn: Claim Dispute PO Box 5000 Farmington, MO 63640 NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted. | Fax: n/a Phone: 833-510-4727 Email: n/a | No |