Claim Reconsideration Process

1. Claim Reconsideration Process Donna Mitchell, Provider Resolutions Manager

2. Claim Reconsideration Overview • • A claim reconsideration is defined as any payment dispute (paid or denied) that a provider would like to have reviewed for further consideration. • • All reconsiderations must be submitted in writing on the Virginia Premier Claim Adjustment form via mail within 60 days of the provider remittance date.

3. Claim Reconsideration Overview • All providers are encouraged to contact Claims Customer Service at 1-800-727-7536, Option 4 if a disputed claim is not responded to within 30 days of submission. • Customer Service Representatives can assist with the following claim inquiries: • Verifying status • Researching issues and denials • Identifying if an issue can be resolved over the phone

4. Claim Reconsideration Tiered Review Process • Virginia Premier follows a three-tiered escalation process for claim payment disputes • The initial reconsideration is reviewed by the Virginia Premier Research and Resolutions Team • The second level reconsideration is reviewed by a member of the Management Team • The third level reconsideration is reviewed by the Reconsideration Committee • Each subsequent escalation resets the 60-day follow-up period from the last remittance date when submitting an additional reconsideration. • All additional escalations must continue to be submitted using the Claim Adjustment Form, notating the level of escalation • (1st, 2nd or 3rd Level Reconsideration)

5. Next Steps • In cases where a provider issue is not resolved by Claims Customer Service, or there are additional questions related to the submission or standards for reconsiderations, providers should contact their Provider Services Representative. • Provider Services Representatives will obtain as much information as possible related to the unresolved issue/request and forward to the Provider Resolutions Manager for additional research and follow-up.

6. Questions