Medical Necessity Appeals
An appeal is the request for review of 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.
Appeal Resolution Time Frame
The review may be requested in writing or orally and will be resolved within 30 days.
- Oral requests for appeals within the standard timeframe, must be resolved within 30 days of receipt of the appeal.
- Members may request Buckeye to review the Notice of Adverse Action to verify if the right decision has been made.
Expedited appeals: may be filed for a pre-service denial when either Buckeye Health Plan or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal.
If a member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals:
- Are issued as expeditiously as the member’s health condition requires, to not exceed 72 hours from the initial receipt of the appeal.
- A 14 calendar day extension may be added by Buckeye
- If the member requests the extension, or
- If Buckeye provides evidence satisfactory to the Department of Health Services (DHS) that a delay in rendering the decision is in the member’s interest.
- For any extension not requested by the member:
- Buckeye will provide written notice of the reason for delay to the member
- Buckeye will make reasonable efforts to provide the member with prompt verbal notice of any decisions not resolved wholly in favor of the member and will follow-up in writing within two calendar days of action.
Who Can File an Appeal?
Members or an authorized representative of a member may appeal an adverse determination. This can be the member, doctor or other service provider like a physical therapist. A practitioner with knowledge of the member’s condition may request an expedited appeal on a member’s behalf. Written member consent is not required for expedited appeals requested by the provider. Providers may also submit a request for an expedited appeal orally or via fax.
What are the Timeframes?
The timeframe to file a standard appeal is no longer than 60 calendar days from the day following the mailing date of Buckeye’s notification of adverse determination of the requested service. An expedited appeal is available for Medicaid members when the service is needed more quickly and for all urgent care requests. These expedited appeal decisions and notification will be no later than 72 hours after the appeal request is received by Buckeye. Therefore, it is important that if this type of request is made all documentation should be in order. Expedited appeals are not available for post-service requests.
REMEMBER: If an appeal is not filed in the timeframe outlined above, a request can be made to appeal but must be in writing and include information as to why the request was not submitted timely.
Always remember the documentation is KEY and should include records and other information relevant to the decision and especially address the reason it was denied.
How to File a Claims Appeal on Portal
(not for Reconsiderations)
- Complete an Appeals Review Form (PDF) and save it to your hard drive. Have all your necessary documents ready to upload to the portal.
- Go to our Provider Portal Login to submit your form and all additional documentation. Supported document types include: .jpg, tif, PDF, and tiff.
Once Logged into the Portal:
- Select the Claims tab at the top of the page.
- Click on search and enter the claim # you want to appeal.
- When the claim appears, click on it to bring up the Button Options.
- Select the Appeal button.
- To upload your documents:
- Click on the ‘Browse’ button.
- Find the document(s) you want to upload and attach, much like you were attaching a document to an email.
- Select ‘Attachment Type’ from the drop down. (See types listed above.)
- Select ‘Attach.’ This will attach the document to your appeal request.
- Continue the same process for all documentation you want to attach.
- Select the ‘Next’ button to complete the process.
- Review your claim information to ensure it is correct.
- Select the ‘Submit’ button.
- Once submitted, you will receive a notice of their successful submission and a Confirmation ID#.
- On the main Claims screen, you click on the Submitted tab and see the submission of the appeal.
Note: If an appeal has already been submitted for a claim, you will see a message notifying you that a Claims Adjustment has been previously submitted and no further adjustment can be made today.
If you have questions, please contact Provider Services at 866-296.8731.