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When all or part of an admission or outpatient service at an eligible
facility is denied for failure to meet medical necessity criteria, the
Independence member is held harmless and cannot be billed for the denied day(s)
or service(s). The facility may appeal the denial for lack of medical necessity
through the process detailed below. This process is the exclusive means of
resolving such disputes. Please note that facility appeals for lack of medical
necessity and payment reviews for lack of preapproval may not be pursued
through the member grievance or member appeal processes.
Inpatient and outpatient services
appeals*
Facilities must submit the appeal in writing within 180 calendar days of the
notice of adverse determination notice.
- Inpatient services: For inpatient services, the notice is
the utilization review letter or the peer-to-peer reconsideration
decision.
- Outpatient services: For outpatient services, the notice
is either the initial utilization review letter or the Explanation of
Payment.
The written appeal request must be accompanied by the entire medical record
for the case being appealed. Appeals for denials due to medical necessity
should be mailed to the following address:
Facility Appeals
P.O. Box 13985
Philadelphia, PA 19101
Upon receipt, 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 facility. If there is no change in disposition at
the time of the preliminary review, the appeal review will be conducted by an
external, independent, licensed physician of the same or similar specialty that
typically manages the care under review and who was not involved in the initial
adverse determination or facility peer-to-peer reconsideration decision. A
determination letter will be sent to the facility containing the decision and
detailed explanation.
The decision to uphold or overturn all, or a portion, of the adverse
determination is communicated, in writing, to the facility within 60 calendar
days of receipt of the written appeal request and the complete medical record.
The written determination of the appeal will include the rationale for the
determination. This decision is final and binding.
*Eligible facilities for inpatient
services appeals include, but are not limited to, acute care
hospitals, long-term acute facilities for vent weaning, and inpatient skilled
nursing facilities.
Eligible facilities for outpatient
services appeals include, but are not limited to, acute care
hospitals, freestanding ambulatory surgical centers, and sleep centers.
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