This process excludes post-service and claims-related disputes.Ĭlaim Reconsideration: Follow the claim reconsideration process if you disagrees with the original claim outcome (payment amount, denial reason, etc.). If authorization was denied pre-service or during concurrent review, follow appeal instructions on the notification letter. Wellcare By Allwell Medicare (MAPD, D-SNP & PPO)Īppeal: An Appeal is the mechanism which allows Providers the right to appeal actions of Wellcare By Allwell such as a pre-service prior authorization denial. PA Health and Wellness Attn: Reconsideration Note: if auth/medical necessity denial related, with records attached, will be routed to UM NOTE: Data stored on external storage devices such as USB devices, CD-R/W, DVD-R/W, or flash media will not be accepted.ĭetermination within 30 calendar days of receipt

If there is a claim on file, please follow the process for Claim Reconsideration below. Note: appeals must be filed within 60 days of the notice of determination. Request within 90 calendar days from DOS. Note: If request for Retro-Auth exceeds 90 days from DOS, please see 'Claim Reconsideration' Request P2P within 2 business days of date of denial Note: PHW will make 3 attempts to schedule prior to closing/upholding 2 call attempts by MD prior to closing/upholding Note: After initial auth, ongoing reviews are done via phone/faxįax: Submit ongoing records via fax/phone Non-Urgent: 2 business days of receipt of all necessary info, not to exceed 14 calendar daysįax: Follow fax submission directions located on the applicable form(s) Maternity admit: 1 business day with delivery outcome Observation (>23 hours hours): IP auth within 1 business dayĮR and post stabilization, urgent care, crisis intervention: 2 business days Observation (≤23 hours): one business day for non-par Community HealthChoices Medicaid ProcessĮmergent IP: within 24 hours or next business day This can include a request to reconsider authorization denials if an authorization was required and not obtained (justification should be included). Medical Necessity Appeal: If authorization or retro-authorization was denied, in part or whole, follow the Appeal process.Ĭlaim Reconsideration: Follow the claim reconsideration process if the claim did not pay as expected, but the claim does not need to be corrected. A decision will be made within 30 calendar days following receipt of request, not to exceed 90 calendar days from date of service. Requests for retrospective review must be submitted promptly. Participant was unconscious at presentation, Participant did not have their Medicaid ID card, or otherwise indicated Medicaid coverage, services authorized by another payer who subsequently determined participant was not eligible at the time of service).

Notification of Pregnancy Information and FAQ on indianamedicaid.Retrospective Authorization Review: Retrospective review is an initial review of services provided to a Participant, but for which authorization and/or timely notification to PA Health & Wellness was not obtained due to extenuating circumstances (i.e.

Member Management, Member Benefits and Services Pregnancy Member Management

For Navigators: Quick Tips (PDF) – Important information and common questions to help you assist applicants.

For Navigators: Next Steps (PDF) – Helpful sheet to provide to potential members who chose MHS on their application.

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