2/3/2015
Claim Appeal Process
Welcome!
• Provider Relations Updates
• Claim Appeal Process Changes for 2015
• Reminders
• Paper Claims – Effective Feb. 1, 2015, KMAP will no longer
accept paper claims from KanCare providers. Paper claims
will be submitted directly to the MCOs. SHP & Benefits
Manager addresses are listed in SHP Bulletin #045 (2014
Bulletin List) and in the KMAP Bulletin.
• Flu Vaccine Procedure Codes: We have three new codes
for vaccinating our members against the flu. For details, see
SHP Bulletin #048 (2014 Bulletin List)
• HEDIS Quick Reference Guides – New guides are now
online at SunflowerHealthPlan.com.
– Provider Relations Reps will provide you large print-outs during
office visits in 2015.
– HEDIS pocket flip-books are in the works.
• New Claims Submission Policies – Effective Jan. 1, 2015,
all Corrected Claims, and effective Feb. 1, all Paper Claims
should be free of handwritten verbiage and submitted on
standard red & white UB-04 or CMS 1500 claims forms
along with original EOP. (SHP Bulletin #047)
• Coming Soon! 2015 Provider Manual – The new manual
will be more user friendly and will have the Billing Manual
incorporated into the general provider manual. Look for this
publication in early February.
• Stay up to date on provider news by bookmarking the
online Provider Bulletins listing and by signing up for our
Email Alerts.
http://www.sunflowerhealthplan.com/for-providers/provider-resources/
• Reconsideration:
Providers must appeal in writing or by phone
within 90 calendar days of the date of EOP or Determination Letter.
Medical documentation will be reviewed. An updated EOP will serve
as notification. No form is required.
• Claims Dispute:
Providers must appeal in writing only using the
Claims Dispute Form within 30 days (33 days if hardcopy mailed) from
date on EOP or Determination letter received following
Reconsideration. A letter will be sent for notification. Each claim must
have its own form.
• Reconsiderations and Claims Disputes are mailed to:
Sunflower Health Plan
Reconsiderations <OR> Claim Disputes
PO Box 4070
Farmington, MO 63640-3833
• If you disagree with the decision made in the
dispute/appeal response from Sunflower, you may appeal
to OAH and request a State Fair Hearing within 30 days
(33 days if notice was mailed to you in hardcopy) of
dispute/appeal response from Sunflower.
• Sunflower will respond to Reconsideration or Claim Disputes within 30
days of receipt.
• You must exhaust the Reconsideration and Claims Dispute process
before asking for a State Fair Hearing related to a claim payment
issue.
• Members cannot file an appeal for a claim issue.
• You can NOT balance bill the member for a medical service.
• If you provide a service not covered by Medicaid, you must talk with
the patient prior to the service, document the discussion as well as the
expected charges and get their signature of consent before you can
bill them for the service.
Step of Provider Appeal
Process Send Where Send What Deadline to Submit
Expected Timeline for
Response Notification of Decision
Reconsideration
Call Customer Service:
877-644-4623
Mail:
Sunflower or Specialty Partner address listed in EOP or letter
Claim number
Reason for request
Supporting documentation
Other items requested
Within 90 calendar days from date of original EOP or Determination letter
30 business days Revised or unrevised EOP for same claim number
Claim Dispute/Appeal
Mail:
Sunflower or Specialty Partner address listed in EOP or letter
Claim Dispute form found here:
http://www.sunflowerhealthp
lan.com/for- providers/provider-resources/forms/
or additional form provided with EOP or letter.
Pharmacy disputes only use form found here:
http://www.sunflowerhealthp lan.com/files/2013/01/USS-MAC-Pricing-Inquiry-Form.pdf
Within 30 calendar days from date on EOP or Determination letter received following Reconsideration (33 days if we mailed the notice to you)
30 business days Letter with determination
You may only file for a State Fair hearing after you have completed the appeal process that includes both reconsideration and dispute/appeal filing with determinations received by Sunflower. If you disagree with the decision made in the dispute/appeal response, you may then appeal to the Office of Administrative Hearings and request a State Fair Hearing within 30 days of the dispute/appeal response.
State Fair Hearing
Office of Administrative Hearings (OAH) 1020 Kansas Avenue Topeka, KS 66612 Phone: 785-296-2433
Applicable forms found here:
http://oah.ks.gov/forms.htm
30 days from date of the Claim Dispute/Appeal
Determination letter (33 if we mailed it to you) for this claim *Note- Provider must exhaust Reconsideration and Claim Dispute prior to requesting
Varies at discretion of OAH Written Communication from OAH
2/3/2015
Type of Service
Sunflower Specialty Partner
Provider Appeals:
Post Service or Claims Disputes
*Requires information/forms included in
Appeal section of the Provider Manual
Medical, NF/LTC or HCBS Services None
Sunflower Health Plan
Attn: Reconsideration OR Claim Dispute PO Box 4070
Farmington, MO 63640-3833 High Resolution Imaging National Imaging Associate, Inc. (NIA)
Sunflower Health Plan
Attn: Reconsideration OR Claim Dispute PO Box 4070
Farmington, MO 63640-3833 Behavioral Health Services Cenpatico Behavioral Health
Cenpatico
Attn: Appeals Coordinator 12515-8 Research Blvd., Suite 400 Austin, TX 78759
OR
Fax to: 866-714-7991 Physical Therapy (PT), Occupational Therapy (OT), and Speech
Therapy (ST)
Cenpatico,
Specialty Therapy and Rehabilitative Services (STRS)
Sunflower Health Plan
Attn: Reconsideration OR Claim Dispute PO Box 4070
Farmington, MO 63640-3833 Vision OptiCare
OptiCare
Attn: Claims Appeal Committee PO Box 7548
Rocky Mount, NC 27804 Dental Dental Health and Wellness (DHW)
Dental Health & Wellness Attn: Appeals
PO Box 1432 Milwaukee, WI 53201 Pharmacy US Script (USS)
Email: [email protected]
Fax: 866-912-0334 Include only form found at:
