Pricing disputes and appeals

If you disagree with the  contracted allowable rate applied to a claim or claim line items, follow the pricing dispute checklist and process below.

Some of the most common reasons why issues submitted via the pricing dispute process are invalid, overturned or returned for additional information include:

• Reviewing outdated agreement terms
• Pricing for Medicare Advantage claims occurred in a previous quarter – please refer to our reimbursement policy for Medicare-Based Fee Effective Dates
• Applying commercial reimbursement schedules to Medicare Advantage claims
• Submitting a pricing dispute after an appeal was denied for the same issue
• Submitting a dispute without specific details
• Facility diagnosis-related group (DRG) pricing is applied per the grouper version indicated in your agreement. Please verify your current grouper version matches what is indicated in your agreement prior to submitting a DRG dispute.

If your issue meets the definition of a pricing dispute and you followed our pricing dispute checklist, submit a pricing dispute using the process below.

Note: Disputes or appeals that are not pricing disputes, or that are received from non-contracted providers will be returned with instructions to follow the appropriate appeal process.

Use the Pricing Dispute Form to submit your dispute. Pricing disputes follow the timely claims filing guidelines for claim adjustments.

Disputes regarding payment or offer of payment for claims subject to the Balance Billing Protection Act, with dates of service beginning January 1, 2022, for providers rendering services to members covered by certain alternate-funded employer groups (who are not subject to state laws) must be submitted in writing within 30 business days:

• Fax 1 (855) 357-3172. Please add Federal Balance Billing Rate Dispute or Washington Balance Billing Rate Dispute on the cover page.
• Email: BalanceBilling@asuris.com

For certified mail or very large documents, mail to:
Asuris Provider Disputes
Balance Billing Rate Disputes
PO Box 1248
Lewiston ID 83501-1248

The party initiating the open negotiation must provide written notice to the other party of its intent to negotiate, referred to as an open negotiation notice, and must include information sufficient to identify the items or services subject to negotiation, including:

• The date(s) the item(s) or service(s) was/were furnished;
• The service code for the item(s) or service(s);
• The initial payment amount or notice of denial of payment, as applicable;
• Any offer for the OON rate; and
• Contact information of the party sending the open negotiation notice.

For claims subject to the Federal Dispute Resolution (FDR) process, the departments of the Treasury, Labor, Health and Human Services and the Office of Personnel Management issued a standard notice that states the parties must use the FDR process to satisfy the open negotiation notice requirement.

The process for submission of all levels of Adverse Determination Provider Appeals or Disputes applies to contracted providers only (appeals for claims/line items denied as provider liability).

Adverse Determination Provider Appeals occur when a contracted provider disagrees with our decision that:

• Medical necessity criteria were not met
• Pre-authorization was not obtained (dispute process)
• NCCI or CCE coding rules apply to a claim or claim line
• Admission notification was not provided (dispute process)
• Line-item audit resulted in a reduced payment or denial (dispute process)
• Items/services billed were not consistent with the medical records provided
• Preventable Adverse Events charges were denied (dispute process)
• Items/services billed were not consistent with our reimbursement/medical policies or contracts
• Claim denied as a duplicate when services were performed more than one time, and payment does not reflect multiple service payment
• Unlisted procedure codes paid a certain amount

• Additional reimbursement denied for the use of a payment enhancing modifier (modifier 22)

Note: Any disputes relating to the contracted allowable rate applied to a claim or claim line must be submitted via the pricing dispute process.

Please refer to the Administrative Manual for more information.

Pre-authorization determinations appearing on the Availity Essentials Authorization dashboard can be appealed using the appeals application. Pre-authorizations appear on the dashboard when they are submitted using the Authorization application or by submitting an inquiry and pinning the authorization to the Authorization dashboard. The Appeals dashboard will show the status of submitted appeals. Access it from Availity Essentials: Claims & Payments>Appeals.

The following pre-authorization determinations appeals cannot be submitted via Availity Essentials:

• Pharmacy pre-authorization
• Pre-authorizations submitted via eviCore (physical medicine) or Carelon  (radiology, sleep medicine or cardiology) 

All post-service provider claims appeals should be submitted via the Appeals application on Availity Essentials. Claims appeals can also be submitted on behalf of members.

If a claims appeal is unable to be submitted through the Appeal application, you will receive a message indicating this when attempting to submit the appeal. Learn more about the Appeals application and view message explanations

Note: The only disputes and appeals that should not be submitted via Availity Essentials are:

• Pricing disputes, which are not appeals and are subject to a separate pricing dispute process
• Disputes that meet our Extenuating Circumstances exception criteria (PDF), which must be submitted via fax
  • Complete the Provider Appeal Form (PDF)
  • Include the subject “Extenuating Circumstance exception request”
• Appeals that Availity cannot process because of file size limits, which may be submitted via secure file transfer protocol (PDF)

• Vendor-related disputes should be submitted per the appeal instructions included in the finding letter received for denied claim(s)

Submit all other provider claims appeals via the Availity Essentials Appeals application.

When a claim is denied because pre-authorization requirements were not followed, you have the right to an Administrative Denial Dispute.

• The documentation must support why the pre-authorization, inpatient notification, or compliance with concurrent review requirements were not completed.

• After review, you will receive notification of the review determination.

  • If the administrative denial is overturned, we may request chart notes for medical necessity review.
  • If the administrative denial is upheld, the determination letter will provide instructions for a second-level internal dispute.

Your dispute must provide documentation evidencing at least one of the following exceptions to obtaining pre-authorization.

1. Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
4. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
5. A surgery that requires pre-authorization occurs in an urgent or emergent situation. Services are subject to review post-service for medical necessity.

6. A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.

Outlined below are suggested documentations that may help support your dispute (as applicable to your case):

• Dated documentation, such as, admission face sheet, obtained at the time of service indicating: The insurance information provided by the patient/representative or the patient's/representative's inability to provide insurance information or the patient's/representative's reporting self-pay.
  Note: Please also include dated documentation when the member’s information was received.
• Dated documentation of your Availity Essentials, Carelon or eviCore authorization inquiry (a screenshot is preferred). Screenshots should include the date, time, transaction number, member information, procedure and diagnosis codes. If you are unable to capture a screenshot, please document the date, time and transaction or reference number.
  • Note: If providing documentation of an inquiry through Availity Essentials, screenshot your information from the Authorizations & Referrals page.
• Verification of no coverage such as Availity screenshot at the time of inquiry (though eligibility at date of service was later confirmed).
• Dated documentation obtained at time of service showing eligibility confirmation from another payer, such as, web eligibility screen print or copy of electronic eligibility confirmation, AND/OR that payer's EOB denying the service as not eligible for coverage (e.g., denied due to alternate primary coverage).
• Applicable office visit chart notes for either the date of service or the referral along with other clinical documentation (as needed), such as, diagnosis, history and physical, failed alternative treatment(s), or interim/alternative treatment(s) as appropriate, indicating the medical necessity for the procedure and the rationale for providing the procedure at that time without prior authorization, (i.e., procedure is time sensitive or emergent).
• A copy of the dated preauthorization request showing the information was entered correctly indicating the member health plan information, and a confirmation showing the authorization request was successfully sent to the appropriate health plan prior to services being rendered.

• Any other documentation felt to support an extenuating circumstance was present.

• Availity Essentials: Use the Appeals application on Availity Essentials to quickly and easiliy submit your appeal and documentation online. Claims appeals can also be submitted on behalf of members.
• FTP: Appeals can also be submitted via our Secure File Transfer Protocol (SFTP) site. Learn how to submit the completed form and supporting documentation (PDF).
• Provider Appeal Form: If you are unable to submit your appeal through the Availity Appeals application, complete and fax the Provider Appeal Form (PDF) to 1 (866) 273-1820.

The member appeal process applies to:

• Claims denied as member payment responsibility.
• Services received from a non-participating provider and not governed by balance billing protections.

• Claim denied for additional information that you are now submitting.

The Appeals for Members (PDF) section in our Administrative Manual applies to appeals submitted by a member or their authorized personal representative or a treating provider on behalf of the member:

• Claims denied as member payment responsibility.
• Services received from a non-participating provider and not governed by balance billing protections.

• Claim denied for additional information that you are now submitting.

• Availity Essentials: Use the Appeals application on Availity Essentials to quickly and easiliy submit a claims appeal on behalf of a member.

• Member Appeal Form: When submitting the appeal on behalf of the member, please return the completed member Appeal Form (PDF) to the appropriate member appeal destination located on the form.

The member must file the grievance within 60 days of the event or incident that precipitated the grievance. A non-participating provider may become a party to an appeal only if the provider has executed a CMS waiver of liability form. (See downloads section.) This form ensures that the enrollee will not be held financially responsible for any changes should the provider lose the appeal. View information about appeals for Medicare Advantage members in the Medicare Advantage Plans (PDF) section of the Administrative Manual.

Disputes governed by a Federal Balance Billing Protection from non-contracted providers regarding a payment or offer of payment must be submitted via a Rate Negotiation Request within 30 business days.

The party initiating the open negotiation must provide written notice to the other party of its intent to negotiate, referred to as an open negotiation notice, and must include information sufficient to identify the items or services subject to negotiation, including:

• The date(s) the item(s) or service(s) was/were furnished
• The service code for the item(s) or service(s)
• The initial payment amount or notice of denial of payment, as applicable
• Any offer for the out-of-network (OON) rate; and

• Contact information of the party sending the open negotiation notice

For claims subject to the Federal Dispute Resolution (FDR) process, the Departments of the Treasury, Labor, Health and Human Services and the Office of Personnel Management issued a standard notice (PDF) for claims subject to the FDR process that the parties must use to satisfy the open negotiation notice requirement.

• Availity Essentials: Use the Appeals application on Availity Essentials to quickly and easily submit your notice and documentation online.
• Fax: 1 (855) 357-3172. Please add "Federal Balance Billing Negotiation Request" on the cover page.
• Email: BalanceBilling@asuris.com
• Mail: For very large documents or documents sent by certified mail:
  Asuris Provider Disputes
  Balance Billing Rate Negotiation Request
  PO Box 1248
  Lewiston, ID 83501-1248
• FTP: Appeals can also be submitted via our Secure File Transfer Protocol (SFTP) site. Learn how to submit the completed form and supporting documentation (PDF).

Disputes governed by a Washington Balance Billing Protection from non-contracted providers regarding a payment or offer of payment must be submitted via a Rate Negotiation Request within 30 calendar days to:

• Fax: 1 (855) 357-3172. Please add "Washington Balance Billing Negotiation Request" on the cover page
• Email: BalanceBilling@asuris.com
• Use the address below for very large documents or documents sent by certified mail
  Asuris Provider Disputes
  Balance Billing Rate Negotiation Request
  PO Box 1248
  Lewiston ID 83501-1248

You may also call our Provider Customer Service number: 800-253-0838

The External Audit and Investigation Appeal Process (PDF) is intended to give providers an opportunity to request reconsideration of audit findings issued by our External Audit and Investigation Department and to ensure we have reviewed all information relevant to the audit findings.

A contracted provider may initiate an appeal of a contract termination, adverse decision due to quality reasons or altering conditions of participation made by Asuris through the Provider Contract Termination Appeal Process.

Most of the appeal panel participants must be clinical peers of the provider. At least one panel participant must be a participating provider who is not involved in network management and who is a clinical peer of the participating provider. Other panel members may include, but are not limited to, the Asuris executive medical director, director of provider contracting and the director of provider network management.

Requests for review of a policy determination not related to a claim may be submitted using the:

• Medical Policy Review Request process, or the

• Reimbursement Policy Request for Review process

Additional information about these processes is available in the Policies (PDF) section of our Administrative Manual.