Dear Peach State Hospital Provider:

This letter serves as notice of a revision to our process for completing Emergency Department (ED) claim reviews. Effective September 1, 2009, Peach State Health Plan(Peach State) will be implementing a new review process that is more aligned with the Georgia Fee For Service Medicaid program and the other Care Management Organizations contracted to provide services to members covered by the Georgia Families program. Peach State adopted the definition for an emergency medical condition as defined in the contract agreement between the Georgia Department of Community Health and Peach State. We continue to support the “Prudent Layperson” policy as set forth in the Balanced Budget Act of 1997, the Medicaid Care Management Organizations Act, and as required by Georgia law. 

ED claims coded with a diagnosis that represents a disease or condition that is recognized as a medical emergency will result in the claims being treated and reimbursed as an emergency service based on the rate negotiated with the hospital.  Claims for emergency services submitted with a diagnosis that represents a disease or condition that is not recognized as an emergency situation will be paid at the ED triage rate, the hospital’s contracted rate, which ever is applicable. The explanation of payment (EOP) will indicate the triage payment and include options to request a reconsideration of the claim in writing within three (3) months of the month of payment. An ED reconsideration request received outside the three (3) month time frame will be denied as untimely.

All requests for reconsideration of an ED claim paid at the triage rate must be submitted in writing to the following address along with the medical records and other clinical rationale (i.e., presenting symptoms, patient age, date, and time of arrival) that supports overturning the triage rate. A Medical Director or his designee will review the information. 

 Peach State Health Plan

ATTN: Peach State Health Plan PLP Appeal

PO Box 3000

Farmington, MO 63640-3800

Peach State will automatically reprocess the claim at the contracted rate, if the decision is made to overturn the triage rate. If the decision is made to uphold the triage rate, you may request a formal appeal by submitting the claim and any additional documentation for consideration under the appeals process. You will receive written notification of the decision once the final appeal determination has been made. Please contact the Provider Solutions department at 866-874-0633 if you have questions or if you need additional information regarding the ED claim review process.

 Sincerely,

 Peach State Health Plan

This entry is filed under News.