Claims, Appeals, and Grievances

Claims, Appeals, and Grievances

Claims

A claim is a request from a patient or health care provider presented to an insurance company for payment for services performed. Click on the hyperlinked Claims heading above for more information and resources regarding claims.

To obtain information on the status of your claims, please log on to the online claims look up website or call our Claims Department at 800-261-3371. Our Claims Department is available Monday through Friday 8:30 a.m. – 5 p.m. Click here for more information on Claims Status/Online Claims Look Up.

A new feature for the online claims look up is that each office will initially register for a master account and then register all other users in their office as subaccounts. Subaccounts will allow multiple users to share the same web portal access without sharing the same user name and password. The employee who is registered as the master account will be responsible for activating and deactivating employee logins. If your office doesn't already have an account, you may also register to obtain online claims statusClaims compliance information is available here.

Appeals

MedStar Family Choice recognizes the right of a member (enrollee) and/or authorized representative or providers (i.e. clinician or facility) to request an Appeal of an Adverse Action (denial) that results in member financial liability or denied service. MedStar Family Choice reviews all appeal requests of Adverse Actions and resolves appeals in a timely, appropriate manner. MedStar Family Choice provides notice of the appeals process in a culturally and linguistically appropriate manner. Methods of informing members and providers about this process include articles in the newsletters, and sections in the member handbook and provider manual. Click on the hyperlinked Appeals heading above for more information and resources regarding appeals.

Grievances

MedStar Family Choice maintains a process for recording and triaging Grievances and Appeals of Grievance resolutions so that they may be resolved in a manner that is consistent with MedStar Family Choice service standards, that is responsive to the needs of members and providers, that meets or exceeds State and regulatory standards and that permits tracking and reporting.

Information current as of: 10/29/18