Provider Disputes or Appeals

Definitions

HAP CareSource™ provides several opportunities for you to request review of claim or authorization denials. Provider Services Call Center specialists are available to help review your claims and advise of next steps at 1-833-230-2102. Actions available after a denial include:

Claim Disputes

If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim. You do not need to file a dispute or appeal. Corrected claims should not be submitted as part of an appeal or dispute. Refer to the Claims page for further information related to claims submission.

Process for Claim Disputes

If you believe the claim was underpaid or overpaid, you can submit a request for adjustment through the claim dispute process. Please note, the preferred method for adjustment requests involving overpaid claims is submission of a recovery request on the HAP CareSource provider portal. You do not need to submit an appeal for this type of review. A request for review of a claim denial should be submitted as an appeal.

Claim disputes must be submitted in writing within 60 calendar days of the payment date on the claim. At a minimum, the dispute submission must include:

• Sufficient information to identify the claim(s) in dispute
• A statement of why you believe a claim adjustment is needed and the expected outcome of the claim adjustment
• Pertinent documentation to support the adjustment

Incomplete requests may be returned with no action taken. The request must be resubmitted with all necessary information within 10 calendar days of the date on the letter notifying you of the incomplete request.

Claim disputes can be submitted to HAP CareSource through the following methods:

• HAP CareSource Provider Portal
• Fax: 937-396-3492
• Mail: HAP CareSource
  Attn: Grievance & Appeals
  P.O. Box 1025
  Dayton, OH 45401-1025

HAP CareSource will render a claim dispute decision within 30 calendar days of receipt. If the decision is to uphold the original claim adjudication, you will receive a letter which will include information on your right to request a claim appeal. If the claim dispute is approved, you will receive a new EOP.

Claim Appeals

If you do not agree with the decision of a processed claim, you will have 60 calendar days from the date the claim dispute decision, denial of payment, remittance advice or initial review determination was mailed to you. Your appeal request should include all grounds for appeal and be accompanied by supporting documentation and an explanation of why you disagree with our decision. HAP CareSource will resolve your claim appeal within 30 calendar days from date of receipt.

If a claim appeal is not submitted in the required time frame, the claim appeal will not be considered, and the appeal will be dismissed. If your appeal is dismissed or denied, you will be notified in writing. For claim denials that are missing documentation, you should upload the necessary documentation on the HAP CareSource provider portal for the claim. 

Utilization Management Peer-to-Peer Process

HAP CareSource provides the opportunity for providers to discuss the Utilization Management (UM) medical necessity determination of a denial or decrease in level of care with HAP CareSource’s Medical Director/Behavioral Health Medical Director or designee within five business days of the notification of the determination. The peer-to-peer process is independent of the appeal process and does not impact the timeframe a member and/or provider has to appeal.

To initiate the peer-to-peer process, please call HAP CareSource’s Utilization Management team at 1-833-230-2102.

Clinical Appeals

If you disagree with a clinical decision regarding medical necessity, we make it easy for you to be heard. Please see the information below this section about how to submit appeals and disputes.

After receiving a letter from HAP CareSource denying coverage, a provider, member or member’s representative can submit a pre-service or post-service clinical appeal. Clinical appeals are reviewed by nurses and physicians not involved in any prior review. They are also reviewed by practitioners with expertise and knowledge appropriate to the item, service, or drug being requested.

• Pre-Service: Denial of an authorization for a service prior to being completed. Members, providers or the member’s representative have 60 calendar days from the date of the initial adverse determination to submit a standard pre-service appeal. If submitted by anyone other than the member, written member consent is required and must be specific to the service requested, is only valid for that appeal and must be signed/dated by the member. You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf form. This is processed as a member appeal. Member appeals (pre- and post-service) will be resolved within 30 calendar days plus any extension, if applicable, for a standard appeal. Member appeals for Children’s Special Health Care Services (CSHCS) members are resolved within 10 days, plus any extension, if applicable, for a standard appeal. Resolutions are provided in writing. See ‘Extending an Appeal’ for more information on expedited clinical appeals. Members have additional appeal rights through DIFS for an external review or may request a state fair hearing. 
• Post-Service Provider Appeal: Denial of an authorization of a service when the service has already occurred. Providers have 60 calendar days from the date of the initial adverse determination to submit a post-service appeal. Post-service appeals are resolved in writing within 30 calendar days.

Expediting Clinical Appeals

If you feel the standard appeal timeframe of 30 days for a pre-service request as noted above could seriously jeopardize the life or health of your patient, you may ask us to expedite a clinical appeal. HAP CareSource does not take any punitive action against providers for supporting their patient’s expedited request.

Expedited appeal requests must be submitted within 10 calendar days of the initial adverse determination and require member written consent, if submitted by anyone other than the member. You can use the Consent for Provider to File an Appeal on Patient/Member’s Behalf Form.

HAP CareSource will review and issue a decision on the appeal as expeditiously as the member’s medical condition requires, but not later than 72 hours from receipt of the appeal. HAP CareSource will make reasonable efforts to provide oral notice of the appeal resolution to the member or representative, in addition to written notification. Providers will also receive notification of the appeal decision. This timeframe may be extended at the member’s request or if in the member’s best interest, or if the expedited review request does meet expedited review criteria. Please reference the section, ‘Denied Expedited Review of a Clinical Appeal’ for more information about what happens if a request for expedited appeal review is denied, and ‘Extending an Appeal’ for more information about extensions.

Please note: There is a limited amount of time to submit additional information for expedited clinical appeals. HAP CareSource will conduct outreach and work with the provider to obtain any needed information for review of the expedited appeal.

Denied Expedited Review of a Clinical Appeal

If HAP CareSource decides not to expedite the pre-service clinical appeal because the criteria for expedited review is not met, HAP CareSource will transfer the request to a standard appeal timeframe beginning the day the expedited request was received. The member will be given prompt oral notice of the decision to not expedite the review. A letter will also be sent to the member or representative notifying them of the reason for the decision to not expedite the appeal, that the appeal is being transferred the standard appeal time frame and will include the member’s grievance rights and time frames, as applicable, as well the right to request an expedited appeal with provider support of serious jeopardy to life or health.

Extending an Appeal

Members may request that HAP CareSource extend the timeframe to resolve any medical necessity appeal request up to 14 days. HAP CareSource may also request an extension of up to 14 days, if the extension is in the member’s best interest. If HAP CareSource extends the appeal, we will make reasonable efforts to give prompt oral notice to the member or representative of the delay and will notify the member or representative in writing of the reasons for the extension and inform the member of the right to file a grievance if the member disagrees with the decision to extend the time frame. HAP CareSource will issue its determination and authorize or approve the service if the appeal is approved, as expeditiously as the member’s health condition requires, but no later than the expiration date of the extension.

How to Appeal

HAP CareSource Provider Portal: Access the Claim Appeals tab on the left. For clinicals appeals, navigate to the Prior Authorizations page, select ‘Status” to look up the authorization request, and select “View Details” to locate the appeals option. At this time, dental, radiology and pharmacy appeals cannot be accepted using the portal. Please submit via fax or mail. 

In Writing: Use the Navigate Provider Claim Appeal Request Form. Please include the following and either mail to HAP CareSource, Attn: Grievance & Appeals, P.O. Box 1025, Dayton, OH 45402-1025, or fax to 1-937-396-3492:

• The member’s name and HAP CareSource member ID number
• The provider’s name and ID number
• The code(s) and why the determination should be reconsidered
• If you are submitting a timely filing appeal, proof of original receipt of the appeal by fax or Electronic Data Information (EDI) for reconsideration
• If the appeal is regarding a clinical edit denial, all supporting documentation as to the justification of reversing the determination

Please note: If you believe a claim was processed incorrectly due to incomplete, incorrect or unclear information on the claim, you should submit a corrected claim within 180 days of the date of service or discharge. You do not need to file an appeal. Refer to the Claims page for further information related to claims submission.

Appeal Resolutions

If the outcome of the claim appeal review is adverse to a provider, HAP CareSource will provide a notice of adverse action.

If an appeal is approved, the payment will appear on the provider’s Explanation of Payment (EOP).

Appeals may be reviewed by the HAP CareSource grievance staff, medical directors, claim staff, provider relations staff and any department with reason to assist in resolving a complaint or appeal.

Exhaustion of CareSource Internal Appeals Process

If HAP CareSource and the provider are not able to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to this code shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 calendar days of being selected, unless HAP CareSource and the provider mutually agree to extend this deadline. All costs for arbitration, not including attorney’s fees, shall be shared equally by the parties.
HAP CareSource requires exhaustion of the internal provider complaint/appeal/dispute process prior to requesting an administrative law hearing.

Rapid Dispute Resolution and Binding Arbitration

Non-contracted hospital providers who have signed the Hospital Access Agreement and who do not agree with the decision of a disputed claim, or group of claims and have exhausted all efforts to reconcile accounts with HAP CareSource may request a Rapid Dispute Resolution Process and the Binding Arbitration Process within 60 days of the claim appeal decision. You may submit your request to Michigan Department of Health and Human Services (MDHHS).

Contact Us

For any questions regarding HAP CareSource’s processes, please contact Provider Services at 1-833-230-2102, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET).