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SHPBN-2019-026 NIA Provider Reconsideration and Appeal Requests

Date: 06/06/19

Reminder to NIA providers regarding reconsideration/appeal requests:

After a therapy service claim is denied due to lack of medical necessity or lack of clinical documentation, please do not send medical records directly to NIA. Claim reconsideration or appeal requests related to a post-service medical necessity review must be submitted to the address listed on your notice of action. Records sent to any other address will not be processed and will be returned to the provider.

Reconsideration Basics (optional step):

  • Requests maybe made by phone, email, in person or in writing to Sunflower or specialty partner address on EOP/letter.
  • Include claim number, reason for request, supporting documentation and other items requested.
  • Must be requested within 120 calendar days of the date of the Notice of Action/EOP. Three (3) additional calendar days will be allowed for mailing time.
  • Reconsiderations will be resolved within 30 calendar days from the date of receipt and notification with be a revised EOP for same claim number.

Sunflower Health Plan – Attention Reconsiderations
PO Box 4070
Farmington, MO 63640-38333

Provider Appeal Basics:

  • The provider will receive a written letter or EOP noting payment amount, denial, or adjustment and receive appeal instructions in that notification, this is the notice of action.
  • Provider appeal request must be filed within 60 calendar days of the date of the notice of action. Three (3) additional calendar days will be allowed for mailing time.
  • Information or documents that support the appeal can be sent by mail as noted in the notice of action or EOP.
  • Sunflower will acknowledge appeal requests within 10 calendar days of receiving the request.
  • Sunflower wants to resolve appeal concerns quickly, and will resolve provider appeals within 30 calendar days of appeal request receipt.
  • The provider will receive a notice of provider appeal resolution letter with the appeal decision, rationale and date of resolution/decision.

Sunflower Health Plan – Attention Appeals
PO Box 4070
Farmington, MO