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[Grievances/Complaints] and appeals

Questions?

Just check your provider manual (PDF) for answers about [grievances/complaints] and appeals. Or contact us.

Just check your provider manual (PDF) for answers about [grievances/complaints] and appeals. Or contact us.

Filing a [grievance/complaint]

Both in-network and out-of-network providers may file verbal [grievances/complaints] with us. We can resolve them outside the formal [grievances/complaints] and appeals process. Your [grievances/complaints] could be based on things like:

 

  • [Policies and procedures
  • One of our decisions
  • A disagreement about whether a service, supply or procedure is a covered benefit, is medically necessary or is done in the appropriate setting
  • Any other issue of concern]

Some provider [grievances/complaints] are subject to the member process. In these cases, we transfer them. These include [grievances/complaints] that you may file on behalf of a member.

Filing an appeal

Both in-network and out-of-network providers have the right to appeal our claims determinations within [60] calendar days of receipt of the claim denial. 

 

You can file an appeal if:

 

  • We denied reimbursement for a medical procedure or item you provided for a member due to lack of medical necessity or no prior authorization (PA) when it was required
  • You have a claim that has been denied or paid differently than you expected and wasn’t resolved to your satisfaction through the dispute process 

File a [grievance/complaint] or appeal now

You can file a [grievance/complaint] or appeal:

Online

You can file a [grievance/complaint] or appeal in your Provider Portal. Need help with registration? Just contact Availity at 1-800-282-4548. You can get help from 8 AM to 8 PM ET, Monday to Friday.

By email

You can email us your  [grievance/complaint] or appeal.

By fax

You can fax your [grievance/complaint] or appeal: [Insert specific provider fax for grievances and appeals]. 

By phone

You can call us with your [grievance/complaint] or appeal: [Insert specific provider phone for grievances and appeals].

By mail

You can send your [grievance/complaint] or appeal to:

 

${plan_name_circle_R}

[Insert specific grievances and appeals address here (rarely the Provider Relations address)]

Reviews of [grievances/complaints] and appeals

Clinical [grievances/complaints] and appeals reviews are completed by health professionals who:

 

  • Hold an active, unrestricted license to practice medicine or in a health profession
  • Are board certified (if applicable)
  • Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case
  • Are neither the same reviewer that made the original decision nor someone who reports to that person 

Member [grievances/ complaints] and appeals overview

 

When members ask, we help them complete [grievance/complaint] and appeal forms and take other steps.

 

Member [grievances/complaints] and appeals

Also of interest: