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Code Review
For claim denials based on codes submitted.
Denial examples: The primary service associated with this procedure has been denied due to submission of an outdated or vague diagnosis code, missing modifier, unlisted codes, or mismatched codes with a patient's gender or age
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Submit Dispute Form—include rationale and supporting documentation with relevant medical records (as necessary) to explain and validate the submitted code.
(Please do not send the entire medical record)
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Denied Authorization
For claim denials due to invalid or denied prior authorization for the service or date(s) of service (DOS).
Denial examples: Authorization not valid for date of service (DOS), Prior Authorization denied
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Submit Dispute Form—include relevant documented rationale explaining why services were rendered following a denied prior authorization request.
(Please do not send medical records; Plan reserves the right to seek additional records to demonstrate medical necessity, if applicable)
Do not use this form for Pre-Service Requests (please see UM for Pre-Service requests).
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Failure to Obtain Authorization Due to Emergency or Urgently Needed Services (GA Only*)
For claims denials for failure to obtain authorization, where the provider can demonstrate that the services rendered were “Emergency and Urgently Needed Services” exempt from prior authorization requirements under 42 CFR § 422.113 and applicable CMS rules.
Denial example: No authorization on file.
*US Family Health Plan Claims Only: Disputes for failure to obtain auth will be treated as Retro Authorization requests, if timely, and must be submitted via ProAuth.
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Submit Dispute Form—include relevant records demonstrating that the services rendered without prior authorization were emergency or urgently needed services, as set forth in 42 CFR § 422.113, and were medically necessary.
(Please attach reason for why prior authorization was not obtained and send applicable medical records)
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Coordination of Benefits Review
For denials due to coordination of benefits issues, such as missing or incomplete primary EOB or conflicts with other health insurance coverage.
Denial examples: OHI must process claim first, resubmit with primary EOB, EOB does not match claim
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Submit Dispute Form—send Corrected Claim with Primary EOB attached, or include other missing information. Do not submit a Dispute Form.
If 'EOB does not match'—submit Dispute Form, include rationale.
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Timely Filing Review
Claim / line denied for being submitted after the plan's allowable filing deadline. This may happen if the original claim wasn't received, a denial was issued for a previously submitted claim, or a delay occurred due to coordination.
Denial examples: Claim submitted beyond timely filing limit, filing deadline exceeded
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Submit Dispute Form—include relevant proof of timely submission such as clearing house reports, EOB from other payers, rejection letters, and any other necessary information.
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Benefit Limitations or Non-Covered Services
For denials resulting from plan coverage rules, such as services that are excluded from benefits or that exceed defined benefit limits.
Denial examples: Service is not a covered benefit, Benefit limit exceeded, Excluded cosmetic procedure
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Submit Dispute Form—include documentation showing why the service should be covered, such as relevant policy references, or other rationale.
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Contractual or Pricing Review
For payment amounts that may not match provider agreement, or incorrect takeback / recoupments.
Denial examples: Paid below contracted rate, unexpected takeback of payment Modifier reduced payment incorrectly
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Submit Dispute Form—include contract or fee schedule and a detailed explanation of the payment issue. Attach relevant remits showing discrepancy, if possible.
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Duplicate Review
Claim/line denials identified as duplicate submissions.
Denial examples: Duplicate claim
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If Incorrectly Identified as Duplicate—submit Dispute Form, include documentation showing why the service should be covered, such as relevant clinical notes, policy references, or other rationale.
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Other / Case-by-Case Review
Use this category for disputes that don’t fall into any of the categories above and may need special handling or clarification.
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Submit Dispute Form—include relevant information and supporting documentation.
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