FLASH: New Appeals Process Effective 8/1/2021

To maintain an organized and thorough provider appeals process, we continually review our own process efficiency as well as that of our provider community, and we also review the timeliness of appropriate resolutions.

As a result of this extensive review, we’ve decided to update our appeals process for physicians, healthcare professionals and facilities. For dates of service August 1, 2021 and after, the appeals process will now have one level of formal appeal after first asking for an informal inquiry on a denied claim. Both informal and formal appeals will need to be entered on our online Provider Inquiry Portal located at Provider.HealthAlliance.org.  Please note, requests to obtain an appeal due to lack of prior authorization will only be granted for extenuating circumstances described in the informal inquiry request. 

The purpose of an appeal is to escalate a reprocessing inquiry decision or bring immediate attention to a critical issue. An appeal should not be the first attempt at communication between the parties for any given issue. You may only appeal for specific reasons outlined in your provider agreement. These include contractual allowances, investigational services, clinical editing, no prior authorization and other specific reasons.

We’ll always try to resolve provider-initiated inquiries through the course of normal operational interactions and our informal inquiry resolution process. Providers must initiate informal inquiries within 90 days of the original denial. To clarify, we define provider informal inquiries as the first contact initiated by the provider to our staff. We accept these inquiries through our Provider Inquiry Portal. To ensure your initial inquiry is handled in the most timely manner please provide as much detail for why an appeal of the denied claim is being pursued.

If you’re not satisfied with the claims processing, administrative determination or outcome of the online claims reprocessing inquiry, as mentioned above, you may submit a formal appeal to us within 90 days from the original denial, unless otherwise stated in your contract. To submit a formal appeal, you must complete the Provider Appeal form located at Provider.HealthAlliance.org.

If you have any questions regarding the appeals process, please contact your provider relations specialist. We’re always happy to help. And thank you for all you do, every day, to keep our members healthy and well.

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