MedStar Family Choice will accept appeals in writing within applicable time frames. Providers acting on their own behalf are defined as those who dispute Adverse Actions when the service has already been provided to the member and there is no member financial liability. A provider appeal must include a clearly expressed desire for re-evaluation/appeal, with an indication as to why the Adverse Action was believed to have been issued incorrectly that MedStar Family Choice is able to investigate.
In response to provider requests for an alternative method of submitting appeals, MedStar Family Choice has implemented an electronic process via fax. Click here to learn about the new electronic process for appeals via fax.
Additional information is available on the Claims Appeals Procedures website.
Additional information is available on the Clinical Appeals Procedures website.
Timely Filing Appeals
The following information was compiled to help clarify the documentation required as valid proof of timely filing documentation. When submitting an appeal request of a denial to substantiate timely filing, please include the following:
For paper claim submissions:
- Submit documentation that the claim was received by MedStar Family Choice including but not limited to FedEx receipt, signature form from the USPS, etc.
- Copy of Explanation of Benefits (EOB) from primary insurer that shows timely submission from the date the carrier processed the claim.
For electronic claim submissions:
- Submit an electronic data interchange (EDI) acceptance report. Please note that confirmation of receipt from the provider’s clearing house would not be acceptable.
- Note: A submission report alone is not considered proof of timely filing for EDI claims. It must be accompanied by an acceptance report.
- The acceptance report must:
- Include the actual wording that indicates the claims was either “accepted,” “received” and/or “acknowledged.
- Show the claim was accepted, received, and/or acknowledged within the timely filing period.
- Copy of the EOB from primary insurer that shows timely submission from the date the carrier processed the claim.