![]() ![]() ![]() There are two forms listed below that a member must complete and give to the provider submitting the formal written appeal. Once we receive the request form, the request for external review will be handled in accordance with federal law and/or state law, depending upon the benefit plan. Meritain Health requires the member to complete an appeals form to indicate a request for external review. Level 3-External appeal. If a member has exhausted the benefit plan’s internal appeal process (or a member is eligible to request an external review for any other reason) that member may request an external review of the benefit plan’s final adverse determination for certain health benefit claims.Level 2-Internal appeal. Meritain Health allows 60 days to request a second-level appeal after a member receives notice of an adverse determination at the first level of appeal.Meritain Health allows 180 days after a member receives notice of an initial adverse determination to request a review of the adverse determination. Level 1-Internal appeal. If a member submits a claim for coverage and it is initially denied under the procedures described within the group plan document, that member may request a review of the denial.Meritain Health’s claim appeal procedure consists of three levels: Please forward this completed form to the privacy officer of the employer or to: The member whose information is to be released is required to sign the authorization form.Īll sections of the form must be complete for the form to be considered. Your signature and your understanding of what it means Purpose: why do you want the information released? Who you authorize to receive your PHI information for example, spouse, child or friend Employee information: if you are NOT the employee of the plan The following is a description of how to complete the form. Non-network providers rendering prior authorized services follow the same timely filing guidelines as original Medicaid guidelines.įor assistance, please call Provider Relations at 1-85.The Authorization for Release of Information form is required according to the guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA), specifically 45 CFR § 164.508 of the HIPAA Regulations. Providers can resubmit hard copy claims directly to Aetna Better Health via mail to the following address:įailure to submit claims within the prescribed time period may result in payment delay and/or denial. Any claims with a frequency code of 5 will not be paid. Providers must additionally stamp or write one of the following labels on the claim if resubmitting a paper claim Resubmission Rebill Corrected bill Corrected Rebillingįor electronic resubmissions, providers must submit a frequency code of 7 or 8. ![]() Providers must include the nature of the request, member’s name, date of birth, member identification number, service/admission date, location of treatment, service or procedure, documentation supporting request, copy of claim, and a copy of remittance advice on which the claim was denied or incorrectly paid. Aetna Better Health will consider a claim for resubmission only if it is re-billed in its entirety.Ĭlaim Resubmission- MLTC Providers have 180 days from the date of remittance to resubmit a claim. New Claim -MLTC claims must be submitted within 120 days from the date of service. Our timely filing limitations are as follows: In accordance with contractual obligations, claims for services provided to an enrollee must be received in a timely manner. Reminder- Timely Filing of Claim Submissions These provider types are not use the UB-92 or CMS-1500 forms. This will be the claim form that will be used for these provider types. If a participating provider does not submit appropriately, claims may be delayed or denied.Ī reference guide to billing has been created to assist Home Care and Social day providers that will be impacted by the change on how to bill on UB-04. Home Care and Social Day Care providers in the Aetna Better Health of New York network will be required to submit all claims on UB 04. Billing Home Care and Social Day Care providers ![]()
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