Claims, Appeals, and Grievances

Once MedStar Family Choice makes a benefit determination, members and providers will be notified in writing at least 10 days before the determination goes into effect. Members and providers are given the right to file an appeal and can request a free copy of all of the information the MedStar Family Choice used when making their determination. Examples of complaints include reducing or stopping a service you are receiving, being denied a medication not on the preferred drug list, or having a preauthorization for a procedure denied.

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 link 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 status.

Claims compliance information is available here.

Appeals

If a complaint is about a necessary service but will not be covered, you or your Provider can ask the MedStar Family Choice to review your request again. This request for a review is called an appeal. If you want to file an appeal you have to file it within 60 days from the date that you receive the letter saying the MCO would not cover the service you wanted. Other people can also help you file an appeal, like a family member or a lawyer. The MedStar Family Choice Claims department accepts correspondence in the form of a reconsideration request. Click on the link above for more information and resources regarding appeals.

Grievances

A grievance is any complaint or dispute (other than an organization determination) expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested.

Examples of grievances include quality of care, not being allowed to exercise your rights, not being able to find a doctor, trouble getting an appointment, or not being treated fairly by someone who works at MedStar Family Choice or at your doctor’s office. See Attachment F of the Member Handbook for the MedStar Family Choice's internal complaint procedure.

 

Information current as of: 09/25/18