Reconsiderations

Reconsideration

• How do I submit a managed care provider reconsideration?

  A provider or provider’s authorized representative may submit a request for reconsideration orally or in writing.

• Is there a managed care reconsideration form?

  • Aetna - No required form                                            
  • Sunflower  https://www.sunflowerhealthplan.com/content/dam/centene/sunflower/pdfs/Provider-Appeal-Form.pdf
  • United  https://www.uhcprovider.com/en/claims-payments-billing.html

• Is there a deadline for filing a managed care provider reconsideration?

  Yes, the timeframe within which a provider or provider’s authorized representative may submit a request for reconsideration with the contractor shall be 120 calendar days of the date of the notice of action, plus an additional three calendar days is allowed for mailing. The provider’s rights to appeal are preserved throughout the reconsideration process.

• What is the process once a managed care provider reconsideration has been submitted?

  • If a provider requests a reconsideration the contractor will review the claim and issue a notice of reconsideration resolution. There is no requirement for the contractors to review the reconsideration and issue the notice within a certain number of calendar days.
  • A provider may terminate the reconsideration process and submit an appeal request within 63 calendar days of the date of the notice of action.
  • If a provider does not submit an appeal within 63 calendar days of the date of the notice of action the provider must wait to receive the notice of reconsideration resolution before filing an appeal.

• What documents do I need to submit for a managed care provider reconsideration?

  Providers should follow the submission requirements for each MCO for reconsideration. Providers are encouraged to include the claim number, reason for the request, and supporting documentation with their request.