Pre-Service Provider Appeals: (no claim submitted)
A pre-service appeal is the request for review per a “Notice of Adverse Action.” A “Notice of Adverse Action” is the denial or limited authorization of a requested service, including the:
- Type or level of service.
- Reduction, suspension, or termination of a previously authorized service.
- Denial, in whole or part of payment for a service excluding technical reasons.
- Failure to render a decision within the required timeframes.
- Denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Buckeye Health Plan network.
Post Service Provider Disputes/Appeals: (claim submitted)
Provider claim disputes/appeals are any provider inquiries, complaints, or requests for reconsiderations ranging from general questions about a claim to a provider disagreeing with a claim payment or denial. While these disputes can come in through any avenue (e.g., provider call center, provider advocates, BHP’s provider portal), they do not include inquiries that come through ODM's Provider Web Portal (HealthTrack).