Provider Disputes or Appeals

Definitions

We provide 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

Claim Disputes

A dispute is a formal review of the processing of a claim by HAP CareSource (excluding denials based on medical necessity) and is typically submitted prior to submitting a claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial.

View Claim Disputes

Claim Appeals

Claim Appeals

A claim appeal is a written request by a provider to review the denial or payment of a claim due to processing errors.

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Clinical Appeals

Clinical Appeals

A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from the HAP CareSource Utilization Management department. You may submit clinical appeals pre- or post-service. All pre-service appeals are member clinical appeals and require the member’s written consent if requested by anyone other than the member. HAP CareSource will resolve your clinical appeal within 30 calendar days or 10 calendar days for members enrolled in the CSHCS program from date of receipt. For more information about requirements for pre- and post-service appeals, view the Clinical Appeals section below.

View Clinical Appeals

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 a dispute.

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 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 Appeal: Denial of an authorization of a service when the service has already occurred. 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. 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.

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).