Claims Reconsideration

Partners works closely with providers to resolve their issues. However, if a provider is dissatisfied with a claims processing outcome, they can submit a Reconsideration Form. Claims analysts will review the submitted claim for accuracy and provide the research outcome. If the provider remains dissatisfied after the claims reconsideration process, they have the option to File a Grievance/Complaint.

Provider Dispute Process

Partners’ provider dispute process serves as an informal reconsideration of its decision or action. However, providers have the option to be represented by an attorney during the appeals process.

In cases of provider payment suspension or withholding, appeals will be limited to determining whether Partners had good cause to initiate the action. The appeal will not address whether the provider has engaged in fraud or abuse.

Partners offers appeal rights for both Medicaid and State-funded providers. A participating provider may appeal an adverse decision for the following reasons:

• Program integrity-related findings or activities.
• A finding of waste or abuse by Partners.
• A finding or recovery of an overpayment by Partners.
• Withholding or suspension of a payment due to waste or abuse concerns.
• Termination or non-renewal of a contract for local health department care/case management services.
• Decertification of an Advanced Medical Home+ or CMA (for Medicaid providers only).
• Violation of terms between Partners and the provider.

Out-of-network providers may appeal for the following reasons:

• An out-of-network payment arrangement.
• A finding of waste or abuse by Partners.
• A finding or recovery of an overpayment by Partners.

A participating provider may submit a written request using the Dispute Resolution Form below or on ProviderCONNECT, within 30 calendar days of:

• Receiving written notice from Partners regarding the decision that triggered the right to appeal.
• A required action by Partners that was not taken.

If the provider does not submit a request within the required timeframe, Partners’ decision becomes final, and the provider loses the right to further appeal. The disputed action or decision will not be put on hold or extended unless agreed upon in writing by Partners. However, Partners may extend the appeal request deadline by 30 calendar days for good cause, such as the need to gather extensive supporting documentation.

Providers will receive a copy of the Dispute Resolution Form along with the notification of action or decision taken by Partners. Providers may also request the form by phone or in person, and the appropriate staff member will assist them.

The Provider Appeals Resolution Form collects the following information:

• The nature of the issue.
• Any previous attempts to resolve it.
• Any additional relevant information the provider wishes to submit.

Providers may submit additional documentation via email, mail, special delivery, hand delivery, ProviderCONNECT or other written communication methods. Originals should not be submitted unless specifically requested. Partners is not obligated to return submitted documents unless agreed upon in writing.

Partners’ Tailored Plan Provider Grievance and Appeals Policy

Partners’ Provider Dispute Resolution Form

If you have questions regarding the Dispute Resolution Process, call 1-877-398-4145 or email Provider_Disputes@PartnersBHM.org.