Clinical Appeals Procedures

Provider Appeals

All clinical appeals must be submitted in writing within 90 business days from the date of the adverse determination (denial)/EOB. Send a written request with all supporting documentation, such as clinical documentation. Please include an explanation for appeal (why the provider believes the claim was denied incorrectly) on the Medicaid Formal Medical Necessity Appeal Form or cover letter.

Mail the appeal information to the following address:

MedStar Family Choice
P.O. Box 43790
Baltimore, MD 21236
Attn: Clinical Appeals Department

A provider appeal must include a clearly expressed desire for re-evaluation, with an indication as to why the denial was believed to have been issued incorrectly. An acknowledgement of receipt of the appeal (first and second level) will occur within five business days of receipt. MedStar Family Choice resolves appeals regardless of the number of appeal levels allowed within 90 business days of receipt of the initial appeal.

Second level appeals must be sent to the address listed above within 30 calendar days of the first level appeal notification letter and should also have the Medicaid Formal Medical Necessity Appeal Form attached. The second level appeal is the final level of appeal. Providers will receive a response within 30 calendar days of the receipt of the second level appeal. 

To contact the MedStar Family Choice Clinical Appeals Department, please call 800-905-1722, option 3 or fax 410-350-7896.

 

Member Appeals

A member (enrollee), authorized representative (e.g. parent, guardian, etc.), or provider (i.e. clinician or facility) acting on behalf of a member may request an appeal that results in financial liability or denied services to a member.

Members must provide written consent for a provider or Authorized Representative to appeal on their behalf via the Provider Permission Form for Member Appeal or any other format. The Appeal Review process begins at the time MedStar Family Choice receives the member consent.

All member appeals must be submitted in writing within 60 business days from the date of the adverse determination (denial). Send a written appeal request with all supporting documentation, such as clinical documentation. Please include an explanation for appeal (why the provider believes the claim was denied incorrectly) on the Medicaid Formal Medical Necessity Appeal Form or cover letter.

Mail the appeal information to the following address:

MedStar Family Choice
P.O. Box 43790
Baltimore, MD 21236
Attn: Clinical Appeals Department

An acknowledgement of receipt of the appeal will occur within five business days of receipt. Member appeals have only one level.

To contact the MedStar Family Choice Clinical Appeals Department, please call 800-905-1722, option 3 or fax 410-350-7896.

Information current as of: 11/28/18