Providers

Appeals

Resolving claims issues for Steward Health Choice Generations Providers.
If you are a Steward Health Choice Generations Contracted Provider:

Steward Health Choice Generations would like to assist you in resolving your claims issues.

If a claim is denied or you disagree with a payment:
Please call our Member Services Department at 1-844-457-8943. The Member Service Representative (MSR) will review the claim issue with you and send a referral sheet if an adjustment is required. This referral will be routed to the Steward Health Choice Generations Claims Team lead for research and determination.

The claim in question must be timely (1-year from date of service or 60-days from date of last adverse action).

If the claim is paid correctly and no adjustment is necessary, then a new line will be entered under the same claim number and a note will be entered detailing the findings of the research.

If the claim is paid/processed incorrectly, then an adjusted line will be added for each claim line that is paid incorrectly. A note will be added to the claim detailing the adjustment, and indicated if an additional payment will be made or if a recoupment for an overpayment is needed.

If you require a call back from the adjuster regarding the determination, please make the request when speaking with the MSR so it may be noted on the referral.

If you are NOT a Steward Health Choice Generations Contracted Provider:

Non-contracted providers are permitted to file a standard appeal for a denied claim only if you complete a Waiver of Liability Statement (WOL), which provides that you will not bill our member regardless of the outcome of the appeal. The WOL Statement is available on our website or by calling Steward Health Choice Generations at -1844-457-8943. Corrected claims should not be submitted as an appeal. They are considered a new claim and should be sent to the Reimbursement Services Department for an Initial Organization Determination.

New claims should be mailed to:
Steward Health Choice Generations
Attn: Reimbursement Services
P.O. Box 52033
Phoenix, AZ 85072-2033

A Standard Appeal may be filed for payment requests by utilizing the following steps.

  • A Provider may request a standard reconsideration by filing a signed, written request with Steward Health Choice Generations within 60 calendar days from the date of denial. This request must be accompanied by a WOL Statement, name of the member, information identifying which denial is being appealed, and contact information for the appellant. If the WOL Statement is not provided then every effort will be made by Steward Health Choice Generations to obtain it. If the WOL Statement is not received within 60 calendar days, then the request for reconsideration will be forwarded to the Independent Review Entity (IRE) with a request for dismissal.
  • Steward Health Choice Generations will mail an acknowledgement letter to the non-contracted provider within 5 calendar days of receipt.

    Mail requests to:

    Steward Health Choice Generations
    Attn: Provider Appeals
    P.O. Box 52033
    Phoenix, AZ 85072-2033

  • Once the request for expedited or standard reconsideration is received and logged, you may be contacted to provide additional information in order to review the case. Steward Health Choice Generations must contact you within 24 hours of the initial request for an expedited reconsideration if additional information is needed.
  • Steward Health Choice Generations will make its reconsideration determination as expeditiously as the enrollee’s health condition requires, but no later than 72 hours (or up to 17 days with an extension) after the request for an expedited reconsideration, no later than 30 calendar days from the date it received the request for a standard pre-service reconsideration and no later than 60 calendar days from the date it receives the request for a standard payment reconsideration.
  • If you require a call back from the adjuster regarding the determination, please indicate so when speaking with Member Services so it may be noted on the referral.
  • If upon reconsideration, Steward Health Choice Generations overturns its adverse organization determination denying a request for payment, then Steward Health Choice Generations will issue its reconsidered determination and send payment for the service no later than 60 calendar days from the date it received the request for a standard reconsideration.
  • If Steward Health Choice Generations affirms, in whole or in part, its adverse organization determination, you will be notified in writing and a case file will be prepared and sent to the Independent Review Entity (IRE) contracted by CMS.
  • If the IRE reverses the original determination then payment will be made within 30 calendar days from the date Steward Health Choice Generations receives the notice of the reversal.
  • If the IRE affirms the original determination, and the amount remaining in controversy meets the appropriate threshold requirement ($160.00 in 2018) then the provider or beneficiary has a right to a hearing before an Administrative Law Judge (ALJ).

The Request for Hearing must be in writing and must be filed with the entity specified in the IRE’s reconsideration notice within 60 days of receiving the adverse determination.


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