This provider dispute process is an informal reconsideration by Partners of its decision or action; however, Partners allows providers to be represented by an attorney during the appeals process.

Partners limits the issue on appeal in cases of suspension or withhold of provider payment to whether Partners had good cause to commence the withhold or suspension of provider payment. Partners will not address whether the provider has or has not committed fraud or abuse.

Partners will offer providers appeal rights for Medicaid and State-funded providers.

Partners must allow a participating provider to appeal an adverse decision. Appeals to Partners are available to a network provider for:

1. Program Integrity-related findings or activities
2. Finding of waste or abuse by Partners
3. Finding or recovery of an overpayment by Partners
4. Withhold or suspension of a payment related to waste or abuse concerns
5. Termination of, or determination not to renew, an existing contract for Local Health Department care/case management service
6. Determination to decertify an Advanced Medical Home+ or Care Management Agency (applicable to Medicaid providers only)
7. Violation of terms between Partners and provider

Partners must allow a provider to appeal an adverse decision. Appeals to Partners are available to an out-of-network provider for:

1. An out-of-network payment arrangement
2. Finding of waste or abuse by Partners
3. Finding or recovery of an overpayment by Partners

A participating provider can submit a request in writing using the Dispute Resolution Form, which can be found on the Partners’ website or the provider web portal, within 30 calendar days on which:

1. Provider receives written notice from Partners of the decision giving rise to the right to appeal
2. Partners should have taken a required action and failed to take such actions

If the provider fails to meet the timeframes to request initiation of the Provider Appeals Process, Partners’ decision becomes final, and the provider may not further exercise the Provider Appeals Process. The action or decision being disputed will not pend or be extended during this dispute process unless expressly agreed in advance in writing by Partners. However, Partners will extend the timeframe by 30 calendar days for providers to request an appeal for good cause shown as determined by Partners. Partners will consider the voluminous nature of required evidence/supporting documentation as good-cause reasons to extend the timeframe.

1. The provider will receive a copy of the Dispute Resolution Form, along with the notification of action or decision taken by the LME/MCO. A provider may also contact Partners by telephone or in-person, and the appropriate staff person will help the provider obtain a copy of the Provider Appeals/Dispute Resolution Form.
2. The Provider Appeals Resolution Form collects the following information, at a minimum:

1. 1. The nature of the problem
   2. Previous attempts, if any, to resolve it
   3. Any other pertinent information that the provider feels is important

3. In addition, the provider may submit additional information in writing either by electronic mail, surface mail, special delivery, hand delivery, provider web portal or other source of written communication. The provider will not submit originals unless requested to do so. Partners is under no obligation to return documents submitted by a provider in support of its dispute unless expressly agreed on in advance in writing.

Partners Tailored Plan Provider Grievance and Appeals Policy

Partners’ Provider Dispute Resolution Form

If you have questions regarding the Dispute Resolution Process,

contact Tricia Plaster at provider_disputes@partnersbhm.org  or call 828-325-8150.