Provider Appeals

Who can file a Provider Appeal?

• Any provider
• Shylo
• Only People that middle name is Surgin
• Only INN Providers

Providers have to have Member approval to file an appeal?

• True
• False
• True only on Mondays
• Maybe

Providers may not appeal any issues that are considered member benefit or contractional reasons for example:

• Deductible/Coinsurance
• 42
• Their least favorite procedures
• Just kidding they really can

Providers may not appeal any issues that are considered member benefit or contractional reasons for example:

• Deductible/Coinsurance
• 42
• Their least favorite procedures
• Just kidding they really can

TRUE or False?A members appeal takes precedence over provider appeals?

• True
• So false
• I don't know, what does Shylo say?
• Do you really have to ask?

True or FALSE Providers will have a 100 calendar days from the claim adjudication date to sumbit Level Billing/Coding dispute?

• True
• False
• What does Madea say?
• only if it feels right.. it is up to CSP decision.

The provider appeals reviews will be completed with in:

• 45 business days
• 45 calendar days
• 45 days
• 45 hours

Level I Provider appeals process for Billing/Coding disputes apply to :

• Integral parts of a primary services, Mutually Exclusive Services, Services not eligible for seperate reimbursement, Incidental procedures denials, Surgical Global Period denials
• Medically Exclusive only
• When Shylo says so.
• Integral parts of a primary services, Mutually Exclusive Services, Services not eligible for seperate reimbursement

Level II Appeals for billing disputes/Medical Necessity are available to:

• any Provider
• Only NC providers
• SC and NC Providers
• Providers name Marvalo

Level II appeals must be submitted before:

• the 91st calender day
• The sun sets on the third calendar day.
• Whenever the Provider feels like it.
• Only after the member demands it of the provider in a detailed letter.