Provider reconsideration process

The claims payment review and reconsideration steps include:

Request for reconsideration (first-level review)

Post Service Non-Authorization Related and Pre-Payment Dispute

Post Service Authorization Related and Clinical Review Authorization Dispute

  • Coding review
  • Contract denials
  • Pricing disputes
  • Timely filing
  • Pre-payment review denials
  • Authorization denials
  • Clinical review denials

Process

Process

Initial intake and documentation of the claim dispute is done electronically on the Provider Portal, Fax, Mail or over the phone by calling Provider Assistance Unit 1-888-767-4670.

  • Exception: Pre-Payment Reconsiderations are done by fax or mail.
  • First-level review would include a written health plan decision letter back to the provider.

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.

Form

Form

Select the First-Level Reconsideration box.

No form - Reach out to the Provider Assistance Unit for call reference number by calling 1-888-767-4670.

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.)

Post Service Non-Authorization Related and Pre-Payment Dispute

Post Service Authorization Related and Clinical Review Authorization Dispute

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

Process

Process

Form

Form

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:

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