Appeals Process

PROVIDER COMPLAINTS

Peach State Health Plan's provider complaint system permits providers to dispute Peach State Health Plan's policies, procedures, or any aspect of Peach State Health Plan administrative functions (including the process by which Peach State Health Plan handles Adverse Benefit Determinations and Explanation of Payment), other than the specific claims and appeal matters described above.

Providers may consolidate complaints of multiple claims that involve the same or similar payment or coverage issues, regardless of the number of individual patients or payment claims included in the bundled complaint. Provider complaints must be submitted in writing within thirty (30) Calendar Days of receipt of Adverse Benefit Determination, Explanation of Payment or administrative function to the Peach State Health Plan Provider Complaint Coordinator at the address below:

Peach State Health Plan
1100 Circle 75 Pkwy
Suite 1100
Atlanta, GA 30339
Attn: Provider Complaint Coordinator

An acknowledgement letter will be sent within ten (10) business days of receipt of the complaint. If the initial determination is upheld, the provider will be notified in writing within thirty (30) calendar days of Peach State Health Plan's receipt of the complaint.

CLAIMS ADJUSTMENT

Providers may resubmit a claim(s) to correct a simple billing error or to request an adjustment if there is a belief that the payment made by Peach State is incorrect. In order to be considered for payment ,claims in this category must be received within six (6) months from the month in which the service was rendered or within three (3) months of the month of payment on the

EOP, which is later. Please include the word "resubmission" and the claim number on the claim form to help us identify that this is a resubmission of an existing claim. A Provider Adjustment form must be completed for all resubmission requests along with the supporting documentation. Your claim will be reviewed and a decision rendered based on the information provided.

Requests for Claim Adjustments that involve like or similar issues may be batched together using one Provider Adjustment Request Form. The form should clearly describe the issue with all supporting documentation attached and indicate the number of claims included.

The Claim Adjustment should be sent to:

Peach State Health Plan
P.O. Box 3030
Farmington, MO 63640-3800

CLAIMS APPEALS

If you are not satisfied with result of your Claim Adjustment request, you may submit a written appeal within 30 days of the decision. You will receive acknowledgement of your written appeal within 10 days of receipt. Appeals received after the thirty (30) day time frame will not be considered for failure to appeal within the time frame.

Peach State will allow providers to batch multiple claim appeals for claims that are similar in nature submitted under the same Appeal Letter. The Letter of Appeal must indicate the nature of the complaint and the number of items attached.

A decision will be rendered within thirty (30) days of receipt of the appeal and you will receive notification of the decision via the EOP notice or written correspondence. Provider Appeals should be mailed to:

Peach State Health Plan
Attn: Provider Appeals
P.O. Box 3000
Farmington, MO 63640-3800

FILING AN APPEAL

An Appeal is a request for review of an Adverse Benefit Determination is defined below. The Appeal Process includes Step 1 which is an Appeal Process and Step 2 which is a State Fair Hearing (Medicaid members) or Formal Appeal Process (PeachCare for Kids® members).

An Adverse Benefit Determination is the denial or limited authorization of a requested service including the type or level of service, the reduction, suspension or termination of a previously authorized service, the denial in whole or in part of payment for a service, the failure to provide services in a timely manner or the failure of the health plan to act within timeframes for grievances and appeals. Providers may request on behalf of a member an Appeal of an Adverse Benefit Determination. The provider must obtain and provide to Peach State Health Plan a written consent of the member to file an Administrative Review on behalf of the member.

WHO MAY FILE AN APPEAL?

A Peach State Health member.
A person named by the Peach State Health member.
A provider with written member consent.
A legal representative of a deceased member’s estate

APPEAL PROCESS

An Appeal is a request for review of an Adverse Benefit Determination. An Appeal is a formal reconsideration of a service which has been denied or a previously authorized service which has been suspended, terminated, or reduced. A member must send an Appeal to Peach State Health Plan within 60 calendar days from the date of the Notice of Adverse Benefit Determination. If the request is not received within 60 calendar days from the date of Notice of Adverse Benefit Determination, it is considered untimely. If this occurs, you will receive written notice and the request will be closed.

As a provider, you may request an Appeal on behalf of a member but must obtain and provide to Peach State Health Plan a member’s written consent.

A member may make request for an Appeal by phone or in person by calling Member Services toll free at 1-800-704-1484. If the member is hearing impaired they can call 1-800-659-7487. The member must also send Peach State Health Plan a signed letter confirming their request within 30 calendar days of their oral request. If Peach State Health Plan does not receive a written request within 30 calendar days from the date of the member’s oral request, the appeal will be closed.

Upon receipt of the appeal, we will send the provider and the member a letter within 10 calendar days letting you know we received an appeal request.

A health care provider who was not involved in the previous decision-making and who has appropriate clinical training and experience in treating the member’s condition or disease will review the appeal. We will send you and the member a letter that will include the decision and reason for the decision. We will do this within 30 calendar days for pre-service appeal request or within 30 calendar days of the post-service appeal request or as expeditiously as the member’s health requires and it will be written in the language in which the administrative review request is received.

You can provide additional information and receive a copy of the documents used in the administrative review at any time during the administrative review process.

Peach State Health Plan may request a 14 calendar day extension if there is need for additional information and the delay would be in the member’s interest. If this occurs, we will notify you and the member in writing. If the member feels they may need more time to complete the review, they may call Member Services at 1-800-704-1484 and ask for an extension for up to 14 calendar days.

Peach State Health Plan will ensure that no punitive action is taken against the member, member’s authorized representative, legal representative for a deceased member’s estate or provider who requests an expedited resolution or supports the member’s administrative review.

The member can request continuation of benefits until the Appeal is completed, which can be up to 30 calendar days. The member’s request for the benefits to continue must be made within ten (10) calendar days from the date we mailed the Notice of Adverse Benefit Determination letter or before the effective date of the action. The member may have to pay for this care if the decision is not in their favor.

EXPEDITED ADMINISTRATIVE REVIEW

If a decision on an Administrative Review is required immediately due to the member’s health needs, providers may request an expedited Administrative Review. Requests for expedited administrative review should be submitted electronically through the Peach State Health Plan website or by calling 1-866-874-0633. Peach State Health Plan's decision will be provided within 72 hours for the review or as expeditiously as the member’s health condition requires. We will send you a letter with the decision within 72 hours or sooner if the member’s health condition requires it.

If we do not agree that the request of an expedited administrative review is necessary, we will call you right away. We will send you a letter within 2 calendar days letting you know that the administrative review will be reviewed through the standard review process. The member may file a grievance if they do not agree with this decision by calling our Member Services department.

Peach State Health Plan may request a 14 calendar day extension if needed. If this occurs, we will notify you and the member in writing. If the member feels they may need more time before your expedited administrative review is completed, they may call 1-800-704-1484 and ask for the appeals department to request an extension for up to 14 calendar days.

ADMINISTRATIVE LAW HEARING

Peach State Health Plan shall allow a provider that has exhausted the internal provider complaint process or internal appeals process related to a denied or underpaid claim or group of claims bundled for appeal, the option either to pursue the administrative law hearing or to select binding arbitration by a private arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. If the plan and the provider are unable to agree on an association, the rules of the American Arbitration Association shall apply. The arbitrator shall have experience and expertise in the health care field and shall be selected according to the rules of his or her certifying association. Arbitration conducted pursuant to O.C.G.A. §49-4-153 shall be binding on the parties. The arbitrator shall conduct a hearing and issue a final ruling within 90 calendar days of being selected, unless the plan and the provider mutually agree to extend this deadline. All costs of arbitration, not including attorney’s fees, shall be shared equally by the parties.

Provider requests for Administrative Law Haring or Binding Arbitration should be mailed within 15 business days of receipt of the adverse decision to:

Peach State Health Plan
Attn: Administrative Law Hearing Coordinator
1100 Circle 75 Pkwy
Suite 1100
Atlanta, GA 30339

Requests Administrative Law Hearing or Binding Arbitration received after this time frame will not be considered.