Appeals

HCS offers providers a process for appealing a medical bill reimbursement determination or an administrative issue. HCS retains the right to accept only those appeals submitted by a provider if the procedures outlined in this section are followed. Once an appeal request is received, HCS conducts a full and fair investigation of the issue and provides a timely response. Additional information to support the appeal may be required.

Hospitals may appeal a medical necessity/appropriateness determination or an administrative issue. The written request must be received within 60 calendar days of the date of the written adverse determination (unless statutory requirements indicate otherwise).

HCS retains the right to accept only those appeals submitted by a facility if the procedures outlined in this section are followed. Once an appeal request is received, HCS conducts a full and fair investigation of the issue and provides a timely response. Additional information to support the appeal may be required.

Information Required with Submission of Appeal

The appeal must be submitted in writing and include the following information:

• Facility’s name and division/location
• Full name and address of claimant(s)
• Claim number
• Admission and discharge dates
• Details of disputed determination
• The result sought
• Cover letter indicating rationale for the appeal
• Copy of the claimant’s complete medical record (must be legible and organized)
• Date and signature of hospital representative

Submit the appeal to:

Level 1 Appeal Related to Medical Necessity/Appropriateness Determinations

This appeal is reviewed by an HCS Medical Consultant who did not participate in the original determination.

The Medical Consultant issues a determination within 30 calendar days of receipt of the appeal and communicates the determination in writing to the facility. The communication will contain information and directions for requesting a Level 2 appeal.

Level 2 Appeal Related to Medical Necessity/Appropriateness Determinations

This appeal must be received within 60 calendar days of the date of the Level 1 appeal determination letter. It must include the reason a second review is requested and must be for the same dates and services indicated on the Level 1 appeal. The request need not include a second copy of the medical record. A physician member of the Peer Review Committee or an assigned physician from the same specialty reviews all Level 2 appeals.

The representative of the Peer Review Committee reviews all documentation submitted for the Level 2 appeal, as well as the original case file(s). The Peer Review Committee members who participated in the original determination or Level 1 appeal do not vote on the Level 2 appeal. The representative of the Peer Review Committee may seek guidance from consultant practitioners who are trained or who practice in the same or similar specialty as would typically manage the care at issue.

The Peer Review Committee issues a determination within 30 calendar days of receipt of the Level 2 appeal. The determination is communicated to the facility in writing within five business days of the decision.

If the provider disagrees with the reimbursement determination or amount paid, the provider may submit a bill reimbursement appeal to HCS for reconsideration. The provider's request for additional reimbursement must be submitted within 18 months from the date the bill was paid.

A medical bill reimbursement appeal can be faxed to 1-973-622-7265 or mailed to:

Level 1 Appeal

A bill reimbursement appeal must be submitted in writing and include the following information:

• A copy of the bill in question
• A copy of the corresponding Explanation of Payment (EOP)
• A brief statement explaining the reason for the appeal
• Medical records may be required

To ensure a timely response to your appeal, please provide a fax number. A response to the appeal will be faxed to your office within 15 business days of receipt.

Level 2 Appeal

If you disagree with the HCS Level 1 appeal determination, you may submit a Level 2 appeal.

A Level 2 appeal must be submitted in writing and include new information that was not available at the time of the original appeal decision. A response to the appeal will be faxed to your office within 15 business days of receipt.