Provider reconsideration process

The claims payment review and reconsideration steps include:

Request for reconsideration (first-level review)

Initial intake and documentation of the claim dispute is done by the Provider Assistance Unit by calling 1-888-767-4670. A reference number will be assigned. Be sure to obtain your reference number for tracking purposes.

  • First-level review would include health plan decision and response back to provider via a phone call
  • Exclusion - Clinical review denials do not require a first level to be completed by the Provider Assistance Unit

For corrected claims or claim adjustments requests please follow our timely filing guidelines. Requests for first-level reconsideration review follow the time frames below.

Commercial members:

  • Provider has 24 months from the notification date of denial
  • If coordination of benefits is involved, the provider has 30 months from the notification date of denial

Medicare members:

Request for reconsideration (second-level review)

Second-level reconsideration is completed in writing. If you disagree with the first-level review, please use the appropriate reconsideration form to submit a second-level reconsideration. Attach any additional documentation not included with the first-level review to help support services billed. (See grid below.)

For corrected claims or claim adjustments requests please follow our timely filing guidelines. Requests for second-level reconsideration review follow the time frames below.

Commercial members:

  • Provider has 24 months from the notification date of denial
  • If coordination of benefits is involved, the provider has 30 months from the notification date of denial

Medicare members:

Claims second-level reconsideration grid

Post service non-authorization related dispute

Post service and clinical review authorization dispute

Pre-payment dispute

  • Code review
  • Contract denials
  • Pricing disputes
  • Timely filing
  • Authorization denials
  • clinical review denials
  • Pre-payment review denials

Process

Process

Process

Form

Form

Form

Appeal or dispute resolution, approved by the Washington State Office of the Insurance Commissioner (OIC)