Physician Appeals

If you are appealing an FEP or Medicare Advantage claim, please refer to Federal Employee Program (FEP), or Medicare Advantage Provider Appeals

If you are appealing a QUEST claim, please refer to QUEST - Provider Complaints, Grievances and Appeals Process

For the purposes of this document, "Physician" is defined as a medical doctor or as a doctor of osteopathy. If you are not a physician, refer to Non-physician Appeals (Excluding Facilities)

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 from 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 Physician Agreement.

Inquiries about Processed Claims

If you believe a claim was incorrectly paid or processed, 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

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 appeal request. You may submit a request for either an internal billing dispute or medical necessity appeal. HMSA will respond with a final internal determination, as soon as possible, but not later than 60 days from the receipt date.

Expedited appeal requests are only accepted for precertification denials when the precertification (30 days) time period may:

• Seriously jeopardize your patient's life or health,
• Seriously jeopardize your patient's ability to gain maximum functioning, or
• Subject your patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.

Please refer to Appealing a Precertification Denial for more information.

Submission of an Internal Billing Dispute or Medical Necessity Appeal

How to Submit an Internal Billing Dispute or Medical Necessity Appeal

• You must complete HMSA's 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 Physician 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 physicians who have a Participating Physician 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 HMSA's letter explaining the final internal determination. Arbitration is final and binding. For more information, refer to Arbitration

HMSA Akamai Advantage^® is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal.