Claim Reconsideration Process Donna Mitchell, Provider Resolutions Manager 01/2018

Claim Reconsideration Overview • A claim reconsideration is defined as any payment dispute (paid or denied) that a provider would like to have reviewed for further consideration. • All reconsiderations must be submitted in writing on the Virginia Premier Claim Adjustment form via mail within 60 days of the provider remittance date.

Claim Reconsideration Overview All providers are encouraged to contact Claims Customer Service at 1-800-727-7536, Option 4 if a disputed claim is not responded to within 30 days of submission. Customer Service Representatives can assist with the following claim inquiries: Verifying status Researching issues and denials Identifying if an issue can be resolved over the phone

Claim Reconsideration Tiered Review Process Virginia Premier follows a three-tiered escalation process for claim payment disputes The initial reconsideration is reviewed by the Virginia Premier Research and Resolutions Team The second level reconsideration is reviewed by a member of the Management Team The third level reconsideration is reviewed by the Reconsideration Committee Each subsequent escalation resets the 60-day follow-up period from the last remittance date when submitting an additional reconsideration. All additional escalations must continue to be submitted using the Claim Adjustment Form, notating the level of escalation (1st, 2nd or 3rd Level Reconsideration)

Next Steps In cases where a provider issue is not resolved by Claims Customer Service, or there are additional questions related to the submission or standards for reconsiderations, providers should contact their Provider Services Representative. Provider Services Representatives will obtain as much information as possible related to the unresolved issue/request and forward to the Provider Resolutions Manager for additional research and follow-up.

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