Managed Care - Disputed Provider Claims Resolution Process

Section 140.75  Managed Care − Disputed Provider Claims Resolution Process a)         The Department will maintain an electronic provider complaint portal through which a disputed claim between a provider and an MCO is documented, monitored, and resolved. A disputed claim is a determination made by an MCO that denies in whole or in part a claim for reimbursement to a provider for services rendered by the provider to an enrollee of the MCO with which the provider disagrees. b)         A provider or its billing agent may submit to the Department's provider complaint portal a disputed claim only after filing with the MCO's internal provider dispute resolution process, as described in this subsection (b).  Multiple claim disputes involving the same MCO may be submitted in one complaint, regardless of whether the claims are for different enrollees, when the specific reason for non-payment of the claims involves a common question of fact or policy. 1)         The provider's submission to the portal must include the date the disputed claims were filed with the MCO's internal provider dispute resolution process and the corresponding MCO-provided tracking number. 2)         Disputes that are submitted to the MCO internal dispute resolution process may be submitted to the provider complaint portal no sooner than 30 calendar days after submitting to the MCO's internal process and not later than 30 calendar days after the unsatisfactory resolution of the internal MCO process or 60 calendar days after submitting the dispute to the MCO internal process. c)         The Department, within 10 business days after a provider's disputed claims submission to the provider complaint portal, will present the disputed claims to the MCO for resolution. d)         The MCO, within 30 calendar days after receiving the disputed claims from the Department's provider complaint portal, will develop a written proposal to resolve the disputed claims, which shall be electronically transmitted to the provider and uploaded to the provider complaint portal, unless an extension is granted pursuant to subsection (e), resulting in an MCO having 60 calendar days to develop a written proposal. 1)         In the event the MCO requires additional information from the provider to review the disputed claims, the MCO must request the additional information from the provider within 5 business days after receiving the disputed claims from the Department's provider complaint portal, unless the MCO requests an extension within this 5 business day timeframe and is granted an extension pursuant to subsection (e).  When an MCO is granted an extension, the MCO must request the additional information from the provider within 5 business days after receiving the extension. 2)         When additional information is requested from the provider by the MCO within the timeframes described in subsection (d)(1), the provider has 5 business days to respond with the requested information, unless the provider requests an extension within this 5 business day response timeframe and is granted an extension pursuant to subsection (e). When a provider is granted an extension, the provider must respond with the requested information within 5 business days after receiving the extension.  Failure to timely provide the information will result in the disputed claims being closed. e)         During the disputed claims resolution process described in subsection (d), the MCO or the provider may request, through the provider complaint portal, that the Department authorize a single 30 calendar day extension.  The MCO or the provider may submit an extension request during the timeframes established in subsection (d).  An extension request, made by either the MCO or the provider, that occurs after the timelines in subsection (d) must be made no later than 7 calendar days prior to the end of the initial 30 calendar day period.  Approval of the extension is at the Department's discretion.  An approved extension adds 30 calendar days to the initial 30 calendar day period, for a total of 60 calendar days within which the MCO must develop a written proposal to address the disputed claims. f)         A provider that disagrees with the MCO's written proposal or does not receive the MCO's written proposal within the required timeframe has 30 calendar days to request that the Department review the disputed claims and render a final decision. 1)         Within 30 calendar days after a provider's request for Department review, both the MCO and the provider shall deliver all relevant information to the Department, including contact information for knowledgeable personnel. 2)         Within 30 calendar days after the timeframe established in subsection (f)(1), the Department shall provide a written decision on the disputed claims that reflects, and is consistent with, applicable contract terms, written Department policies and procedures, and State and federal statute and regulations. 3)         The decision of the Department is final. Disputes between MCOs and providers presented to the Department for resolution are not contested cases and do not confer any right to an administrative hearing.