Following a review of the AmeriHealth post-service professional provider appeals and grievances processes, which focused on how providers have utilized and how AmeriHealth has operationalized these processes, effective November 1, 2014, we will be rolling out a streamlined appeals process and offering enhanced access to the provider grievance process for all AmeriHealth Pennsylvania and Delaware members and AmeriHealth New Jersey Medicare Advantage members, as follows:

• Billing dispute appeals. There will be two levels of internal review for professional providers. All first-level billing disputes must be received within 180 days of your receipt of the Statement of Remittance (SOR)* or Provider Explanation of Benefits (Provider EOB).
• Grievances. There will be a one-level external review, as described below, by a clinically matched specialist for professional providers. A preliminary internal assessment will be conducted. Note: Appeals not overturned during the original assessment will automatically be forwarded for an external, matched specialty review.

Billing dispute appeals process

AmeriHealth offers a two-level post-service billing dispute appeals process for professional providers. For services provided to any AmeriHealth Pennsylvania or Delaware member or to AmeriHealth New Jersey Medicare Advantage members, providers may appeal those claim denials related to general coding and the administration of claim payment policy as billing disputes.

Examples of billing disputes include:

• bundling logic (integral, incidental, mutually exclusive claim edits);
• modifier consideration and application;
• claims adjudication settlement not consistent with the law or the terms of the provider?s contract;
• improper administration of an AmeriHealth claim payment policy;
• claim coding (i.e., how we processed the codes in the claim vs. the provider?s use of the codes).

The provider billing dispute appeals process does not apply to:

• utilization management determinations (e.g., claims for services considered not medically necessary, experimental/ investigational, cosmetic);
• precertification/authorization/referral requirements;
• benefit/eligibility determinations (e.g., claims for noncovered services);
• audit and investigations performed by the Corporate and Financial Investigations Department;
• fee schedule concerns.

Submission of billing dispute appeal

To facilitate a first- or second-level billing dispute review, submit inquiries to:

• Provider Billing Dispute Appeals
• P.O. Box 7930
• Philadelphia, PA 19101-7930

All first-level billing dispute appeals must be filed within 180 days of receiving the SOR or Provider EOB and should contain all applicable medical records, notes, and tests, along with a cover letter explaining the appeal. First-level appeals will be processed within 30 days of receipt of all necessary information. A billing dispute appeal determination letter will be sent to the provider.

If a provider disputes the first-level provider billing dispute appeal determination, he or she may then submit a second-level provider billing dispute appeal by sending a written request within 60 days of receipt of the decision of the first-level provider billing dispute appeal. The appeal will be reviewed by an internal Provider Appeals Review Board (PARB) consisting of three members, including at least one Medical Director. The decision will then be communicated to the provider and will include a detailed explanation. The decision of the PARB will be the final decision.

If a member appeal, or provider appealing on behalf of the member appeal with the members consent, is filed before or during an open provider appeal for the same issue, the provider appeal will be closed and addressed under the member appeal.

Providers filing a post-service appeal for AmeriHealth New Jersey commercial members should continue to submit these appeals to:

• AmeriHealth New Jersey Provider Appeals
• 259 Prospect Plains Road, Building M
• Cranbury, NJ 08812

Provider grievance process

AmeriHealth offers a one-level post-service grievance process for professional providers. For services provided to any AmeriHealth Pennsylvania or Delaware member or AmeriHealth New Jersey Medicare Advantage members, providers may appeal claim denials related to services (i.e., those considered not medically necessary, experimental/ investigational, or cosmetic) as grievances.

The grievance process does not apply to

• precertification/authorization/referral requirements;
• benefit/eligibility determinations (e.g., claims for noncovered services);
• audit and investigations performed by the Corporate and Financial Investigations Department;
• fee schedule concerns;
• billing dispute appeals.

Submission of provider grievances

To facilitate a grievance review, submit to:

• Provider Grievances
• P.O. Box 7930
• Philadelphia, PA 19101-7930

All grievances must be filed within 180 days of receiving the SOR or Provider EOB and should contain all applicable medical records, notes, and tests, along with a cover letter explaining the grievance. All grievances will be processed within 60 days of receipt of all necessary information. A preliminary review will be conducted. If the determination is to pay the claim, a claim adjustment will be processed and a determination letter will be sent to the provider. All other grievances will be sent to an Independent Review Organization (IRO) for a matched specialty review. A determination letter containing the IRO decision and detailed explanation will be sent to the provider. The decision of the IRO is final.

If a member grievance, or provider filing on behalf of the member grievance, is filed before or during an open provider grievance for the same issue, the provider grievance will be closed and addressed under the member grievance.

Providers filing a post-service grievance for AmeriHealth New Jersey commercial members should continue to submit these grievances to:

• AmeriHealth New Jersey Provider Appeals
• 259 Prospect Plains Road, Building M
• Cranbury, NJ 08812

For more information

If you have any questions, please call Customer Service at 1-800-275-2583 for providers in Pennsylvania and Delaware and at 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey.

*As of January 1, 2014, and continuing through mid-2015, we are in the process of migrating AmeriHealth Pennsylvania members to a new operating platform. Once a member has been migrated to the new platform, providers will no longer receive the current SOR. Professional providers will receive what will be called the Provider Explanation of Benefits (EOB). Once all AmeriHealth Pennsylvania members are migrated in 2015, you will only receive the new Provider EOB for these members.