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Provider Appeals Page

You use the Provider Appeals page to edit a provider appeal.

The Provider Appeals page contains the following panels:

You can open or close certain panels. Click (the plus sign) beside a panel to open the panel. Click (the minus sign) to close the panel.

 

Provider Information Fields

Field Description
Provider Name The name of the provider.
Provider ID

Unique identifier used for a provider of healthcare services.

Format: Up to 15 alphanumeric characters

 

Appeals Fields

Field Description
To view or edit an appeal, in the Appeals table, click the appropriate row. The details for this appeal are displayed in additional panels.
Appeal Case Record Number The appeal reference number used to track the specific case.
Type The appeal type code.
Appeal Date The date of the appeal.
Appeal Status

The current status of the appeal.

Examples: Active, Approved

 

Appeal Details Fields

Field Description
Case Record Number The appeal reference number used to track the specific case.
Case Record Details After you save the appeal, links to the Log Case page with additional details about the specified case.
Program Type

The type of program associated with the appeal.

Examples: Dental, MEAD

If SA/Services option is selected, an SA Number field is displayed. If Claim option is selected, a Claim TCN field is displayed.
Appeal Type The type of appeal.
Reviewer Name The person's name reviewing the appeal.
Assigned Date The date the appeal was assigned.
Previous Appeal Number The previous appeal number, if applicable. This field is view-only.
Continuance Reason The reason for the appeal continuance. This field only displays if Continuance is selected in the Appeal Type field.
Original Denial Date The date the appeal was originally denied.
Reconsideration Denial Date The date the reconsideration of the appeal was denied.
Appeal Date The date of the appeal.
Appeal Results The results of the appeal.
Appeal Status

The current status of the appeal.

Examples: Active, Approved
Appeal Status Update Date The date when the appeal's current status was last updated.
County The county where the appeal was handled.
Claim TCN The claim transaction control number. This field is only displayed if Claim is selected in the Program Type list.
Claim Details After you save the appeal, links to the Claim Detail page in Claims Inquiry.
SA Number

The service authorization number. This field is only displayed if SA/Services is selected in the Program Type list.

If the field contains a valid SA number, the SA Line Items panel is displayed.
SA Details After you save the appeal, links to the Service Authorization page in Claims Service Authorization.

 

SA Line Item Fields

Field Description
Include If checked, indicates this line item is associated with this appeal.
LI #

The number of the line item.

SA Line Status The status of the line item.
SA Line App Status The status of the line item appeal.
SA Line App Result The result of the line item appeal.
SVC Type Code

Indicates whether the service code is a revenue code, procedure code or another type of code.
SVC From Code

The first code in the range of service codes or a single code.
SVC To Code

The last code in the range of service codes.
Req Amount The requested dollar amount for the line item.
Req Units The number of units of service requested for the line item.
Req Rate The dollar amount requested per unit of service.
Req Begin Date The requested begin date for the line item.
Req End Date The requested end date for the line item.

 

Additional Information Fields

Field Description
Requested Date The date the appeal was requested.
Due Date The date the appeal decision is due.
Received Date The date the appeal was received.
Revised Review Date The revised review date, if applicable, of the appeal.
Notification Letter Sent Date The date a notification letter was sent to the member regarding the appeal.
Received 2nd Request Date The date the second appeal request was received.
2nd Revised Due Date The date the second appeal request review is due.
ALJ  Officer The Administrative Law Judge Officer.
Response Requested By The date a response on the appeal is requested.
Motion Type The type of motion being filed.
Date Motion Filed The date when the motion was filed.
Case File Location The place where the case file information is kept.
Client Representative The person representing the client (member or provider).

 

Reconsideration Fields

Field Name Description
ALJ Findings Date The date the appeal reconsideration was ordered by the Administrative Law Judge.
Order Signed Date The date the appeal reconsideration was returned.
Reviewer Name The person who reviewed the reconsideration.
Decision The reconsideration decision of the original appeal.
Decision Date The date when the reconsideration decision was made.
Notification Letter Sent Date The date when the reconsideration notification letter was sent.

 

Administrative Hearing Fields

Field Description
To add an administrative hearing, click Add Administrative Hearing. To edit, in the Administrative Hearing table, click the appropriate row.
Pre-hearing Conference Date The date of the conference held before the hearing.
Exhibit Due Date The date any exhibits must be delivered before the hearing.
Admin Hearing Date The administrative hearing date.
Hearing Results The results of the administrative hearing.
Hearing Status

The status of the administrative hearing.

Example: Open
Docket Number The number assigned to the administrative hearing for scheduling/tracking purposes.
Hearing Officer Name The name of the officer presiding over the administrative hearing.
Hearing Citation ???

 

Informal Review Fields

Field Description
These fields are not displayed if the Appeal Type is Other.
Requested Date The date the informal review was requested.
Acknowledgement Sent Date The date the acknowledgement was sent regarding the informal review.
Sent for Review Date The date the informal review was sent for review.
Due Date The date the informal review decision is due.

 

DHS Formal Review Fields

Field Description
These fields are not displayed if the Appeal Type is Other.
Sent to DHS Date The date the formal review was sent to DHS (Department of Human Services).
DHS Decision Due The date a decision must be made on the formal review.
DHS Decision The decision made by the Department of Human Services.
Notification Letter Sent Date The date when a notification letter was sent to the member or provider, as applicable, regarding the formal review.

 

Version as of 5/16/14.

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