Resolving claims issues for Steward Health Choice Generations Providers.
[Under Chapter 13 Section 70.1 of the Medicare Managed Care Manual, contracted providers do not have appeal rights. Appeals for non payment of services would have to be filed by the beneficiary.] However, Steward Health Choice Generations would like to assist you in resolving your claims issues.
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.
Under Chapter 13 Section 60.1.4 A non-contracted provider on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the provider completes a Waiver Of Liability Statement (WOL), which provides that the provider will not bill the enrollee regardless of the outcome of the appeal. The WOL Statement is available by calling Steward Health Choice Generations at -1844-457-8943. A Standard Appeal may be filed 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. (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).
Once the request for standard reconsideration is received and logged, the physician may be contacted to provide additional information in order to review the case.
Steward Health Choice Generations will make its reconsideration determination no later than 60 calendar days from the date Steward Health Choice Generations receives the request.
If you require a call back from the adjuster regarding the determination, please indicate so when speaking with the CSR 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, a written explanation and 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.