Facilities should refer to the Dispute Resolution (Appeals and Arbitration) process.
If you are appealing an FEP or Medicare Advantage, please refer to Federal Employee Program (FEP) or Medicare Advantage Provider Appeals.
If you are appealing a QUEST claim, please refer to QUEST Integration - Provider Reconsiderations, Grievances, and Appeals Process.
These procedures apply if you are not a medical doctor or doctor of osteopathy. If you are a physician, please refer to Physician Appeals.
If you have questions about how a claim was processed, how it was paid, or why it was not paid, you may ask that the claim be reviewed. Requests for review must be made within one year of your or your agent's receipt of HMSA's original decision to deny or pay the claim. Below are your options if you would like your claim reviewed. Additional information about appeals may be found in HMSA's Participating Provider Agreement.
Inquiries about Processed Claims
You may initiate an inquiry by contacting Provider Correspondence.
A Provider Services representative will review the information on file. If the information indicates that the claim was processed incorrectly, the claim will be reprocessed.
Any determination involving medical or clinical review will be made by an HMSA medical director. You may ask to speak to a medical director.
A follow-up inquiry may be initiated if you subsequently provide additional information or have unresolved questions.
Internal Appeals
The internal appeals process is available to providers who have a Participating Provider Agreement with HMSA.
Appealing a Precertification Determination
Precertification denials may be appealed. For information on submitting a precertification appeal, refer to Appealing a Pre-Certification Denial.
Appealing a Processed Claim
If you disagree with a claim determination and wish to pursue the matter further, you must appeal the decision by submitting a written internal appeal request.
You may submit a request for either an internal billing dispute appeal, or a medical necessity appeal.
| Examples of Billing Dispute Appeals | Examples of Medical Necessity Appeals |
| Bundling and unbundling of codes when two or more CPT codes are billed on the same claim | Denials based on payment determination criteria not being met |
| Reassignment of or reduction in code levels after clinical review | Denials based on services being investigational or experimental |
| Application of a CPT modifier or appropriateness of a payment enhancing modifier | Medical policy criteria not being met |
How to Submit an Internal Billing Dispute or Medical Necessity Appeal
- You must complete the Provider Internal Appeal Request form.
- Your appeal request and any additional information you submit will be reviewed.
- If the appeal pertains to a clinical issue, you may request a review by an Independent Review Organization (IRO).
- HMSA will notify you of its final internal determination within the time period specified in your Participating Provider Agreement.
- If HMSA or the IRO decides in your favor, payment will be made within 30 days of the notification of the final internal determination. If the determination is not in your favor, the letter will explain your right to further appeal through arbitration.
External Appeals
Arbitration
Arbitration is the external review process that is available to providers who have a Participating Provider Agreement with HMSA.
If you are dissatisfied with the final internal determination of an appeal and wish to pursue the matter further, you must request arbitration within 60 calendar days of the date of the final internal determination. Arbitration is final and binding. For more information, refer to Arbitration.
