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SHPBN-2017-014 New Provider Appeal Process

Date: 04/17/17

NEW Provider Appeal Process effective May 1, 2017

If a provider disagrees with a decision for payment or authorization of services after services have been rendered to a member, the provider has a right to access the Sunflower Provider Appeal process. This process includes requesting a reconsideration (optional), provider appeal and State Fair Hearing.

Provider appeals can only be initiated by the provider or provider's authorized representative.

  • Providers must file a request for a reconsideration, by telephone, by email, in writing or in person using the Provider Reconsideration & Appeal Form (available by May 1), within 120 calendar days from the date of the action.
  • Providers do not need to file a reconsideration in order to file an appeal.
  • Providers may terminate the reconsideration process at any time and submit an appeal, within 60 calendar days from the date of action, plus 3 calendar days if the notice is mailed.
  • Sunflower Health Plan will resolve your reconsideration within 30 calendar days from date of receipt.
  • Providers must file a request for an appeal within 60 calendar days from the action, plus three calendar days if the notice is mailed.
  • Providers may only file an appeal in writing and must include the Provider Reconsideration & Appeal Form and send it to:
    Sunflower Health Plan
    P.O. Box 4070
    Farmington, MO 63640-3833
  • Sunflower Health Plan will acknowledge your written request for an appeal in writing within 10 calendar days from the date the request for an appeal is received.
  • Sunflower Health Plan will send a letter of determination and/or resolution of an appeal within 30 calendar days from the date the request for an appeal is received.

Providers that are not satisfied with the resolution of their appeal have the right to a State Fair Hearing. The appeal determination letter provides instructions on how to file a State Fair Hearing, including the timeframes in which you have to file.

Claims that do not clearly indicate they are a "reconsideration" or "appeal" with a reason for the request in writing may be denied as a duplicate claim. For further information, review definitions listed below.

Definitions

  • Appeal: a request for an MCO to review an action
    • Where the claim is not corrected or changed;
    • Where the provider submits in writing indicating they want to appeal; and,
    • Requests to have the claim reprocessed; and,
    • Provides in writing a reason for the appeal (e.g., using the Provider Reconsideration and Appeal Form or letter).
  • Action is defined (for the purposes of provider appeals) as:
    • The denial or limited authorization of a requested service, including the type or level of service;
    • The reduction, suspension or termination of a previously authorized service;
    • The denial, in whole or in part, of payment for a service;
    • The failure to provide services in a timely manner;
    • The failure of an MCO to act within the timeframes provided in the requirements set forth by KDHE.
  • Reconsideration: A claim that has been processed (either partially or fully, paid or denied):
    • Where the provider disagrees with the outcome of the claim; and,
    • Where the claim is not corrected or changed; and,
    • Where the provider does not request an appeal in writing; and,
    • Requests to have the claim reprocessed; and,
    • Provides a reason for the reconsideration (e.g., the claim denied for no auth, but there is an authorization on file).
  • Authorized Representative: any person or entity acting on behalf of the provider and with the written consent of the provider.
  • First Time Claim (FTC)/New Day Claim: The first time a claim is received and accepted into Sunflower's claims processing system.
  • Duplicate Claim: An exact duplicate of a claim that has been previously submitted and accepted into Sunflower's claims processing system that does not include a request for reconsideration or appeal and/or Provider Reconsideration and Appeal Form.
  • Corrected Claim: A claim that corrects, changes or adds information (including, but not limited to primary insurance EOBs, consent forms, and medical records when required, e.g., with unlisted procedure codes) to a previously submitted and processed claim and that:
    • Includes a TOB "0XX7" or Reference Code "7," indicating it is a corrected claim; and,
    • Includes the ICN from the original claim.

 

If you have questions about this bulletin or would like more information about the new provider appeals process, please refer to the revised Grievance and Appeal Process in the Sunflower Provider Office Manual or contact Customer Service at 1-877-644-4623.