MedStar Family Choice-DC will accept appeal requests orally or in writing within applicable time frames. Appeal requests must include a clearly expressed request for the appeal or re-evaluation. The request must include the reason and supporting documentation as to why the Adverse Action (denial) was believed to have been issued incorrectly.
MedStar Family Choice-DC will send a letter to acknowledge receipt of the appeal within two (2) business days of receipt of the appeal request. A decision letter will be sent within thirty (30) days from the date the appeal request was received for standard non-urgent requests.
Provider Appeals
Providers acting on their own behalf are defined as those who dispute Adverse Actions when the service has already been provided to the enrollee and there is no enrollee financial liability. First level appeals must be submitted in writing within 90 business days from the date of the explanation of benefits (EOB) or denial notice, using the Medicaid Appeal Form. The appeal must outline reasons for the appeal with all necessary documentation including a copy of the claim and the EOB, when applicable. Appeal requests for medical necessity decisions must include supporting clinical/medical documentation.
A provider appeal must include a clearly expressed reason for re-evaluation, with an explanation as to why the denial was believed to have been issued incorrectly. An acknowledgement of receipt of the appeal will be sent to the requestor and copies to other providers as applicable, within two business days of receipt of the request.
For questions, please call our Provider Customer Service Line at 800-261-3371, which is available Monday through Friday, 8:00 a.m. to 5:30 p.m.
Instructions for Completing the Medicaid Appeal Form:
-
Fields designated by an asterisk (*) are required.
-
The form must be completed in its entirety to prevent delay in processing the appeal.
-
Use one appeal request per form.
-
Medical records must be submitted for medical necessity requests.
-
Submit a copy of the claim (Only for Administrative appeals).
-
Must select Plan Type (DC), Appeal Type (Clinical or Claims) and the Appeal Level (I).
Enrollee Appeals
Enrollee appeals only have one level. An enrollee, representative (e.g. parent, guardian, friend, etc.), or provider (e.g. clinician or facility) acting on behalf of an enrollee may request an appeal of an Adverse Action when the service has not yet been provided (pre-service), there is reduction of services, or the service has already been provided and there is enrollee financial liability.
Enrollees must provide written consent for a provider or representative to appeal on their behalf via the Provider Permission Form for Enrollee Appeals or any other format. The Appeal Review process begins at the time MedStar Family Choice-DC receives the enrollee’s consent.
All enrollee appeals must be submitted in writing within 60 calendar days from the date on the Adverse Benefit Determination (denial) notice. The enrollee may initiate an appeal orally. However, a written appeal request with all supporting documentation, such as clinical/medical documentation must be sent to MedStar Family Choice-DC for review. Please include an explanation for the appeal (why the enrollee/ provider believes the service was denied incorrectly). Complete all required files on the Medicaid Appeal Form and submit with the appeal.
Required documentation:
-
Medicaid Appeal Form
-
Explanation for the appeal
-
Provider Permission Form for Member Appeals
-
Clinical information (medical records) for date of service
If you have questions, please call us at 800-905-1722, option 3.
Clinical/Medical Necessity appeal requests can be faxed to 410-350-7435.
Administration/Claim appeal requests can be faxed to 410-350-7455.
If the appeal is more than 50 pages, please use our mailing address below for all Provider and Enrollee Appeal requests:
MedStar Family Choice-DC
Appeals Processing
P.O. Box 43790
Baltimore, MD 21236
For prior authorization forms and other forms, please visit the Preauthorization and Utilization Management page.
Information current as of: