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5.6.1 Introduction
The provider claim disputes process affords behavioral health providers
the opportunity to challenge a decision by the Regional Behavioral
Health Authority (RBHA) or ADHS/DBHS that impacts the provider.
Behavioral health providers may dispute issues involving:
- A payment
of a claim;
- The denial
of a claim; and
- The assignment
of sanctions.
Behavioral
health providers will initially file a claim dispute directly with
either a RBHA or ADHS/DBHS, depending upon:
- Which entity
is responsible for the decision; and/or
- If a claim
payment issue, if the dispute involves services to a person enrolled
with a RBHA or a Tribal RBHA.
Behavioral
health providers initially submit a claim dispute to a RBHA when:
- Challenging
a decision of the RBHA; or
- Disputing
a claim payment issue for services provided to persons enrolled
with a RBHA.
Behavioral
health providers initially submit a claim dispute to ADHS/DBHS when:
- Challenging
a decision of ADHS/DBHS; or
- Disputing
a claim payment issue for services provided to persons enrolled
with a Tribal RBHA.
Once the RBHA
or ADHS/DBHS makes a decision regarding a provider claim dispute,
the behavioral health provider may request another review of the
decision, referred to as an administrative hearing.
Many times,
disagreements between a behavioral health provider and the RBHA
or ADHS/DBHS can be resolved through an informal process. Behavioral
health providers are encouraged to try and solve issues at the informal
level before initiating the formal provider claim dispute process.
However, providers should be aware that the formal process contains
very specific timeframes within which to file for a review and/or
hearing and resolving issues through an informal process does not
suspend or postpone these timeframes.
The intent of
this section is to describe the options available to behavioral
health providers to resolve issues and other events related to a
decision of the RBHA or ADHS/DBHS. The section is organized to delineate
the process for filing a claim dispute:
- For behavioral
health providers disputing a decision of a RBHA;
- For behavioral
health providers disputing a decision of ADHS/DBHS; and
- The process
for requesting an administrative hearing in the event a behavioral
health provider does not agree with the claim dispute decision
of a RBHA or ADHS/DBHS.
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5.6.2
References
The following citations can serve as additional resources for this
content area:
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5.6.3
Scope
To whom does this apply?
This applies
to all providers with or without a contract with a T/RBHA who provide
services to persons enrolled in the ADHS/DBHS behavioral health
system.
5.6.4
Definitions
Claim
Dispute
Day
Filed
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5.6.5
Did you know…?
- ADHS/DBHS
and the RBHAs must ensure that when a claim for payment is denied
in whole or in part, or a decision is made to impose a sanction,
the affected provider is advised in writing of the right to file
a claim dispute.
- The entire
provider claim dispute process is outlined on
PM
Attachment 5.6.2.
- ADHS/DBHS
and the RBHAs review individual claim disputes and trend
collective claims disputes for purposes of detecting fraud and
abuse.
5.6.6
Objectives
The objective of this policy is to ensure that providers
understand the procedures for filing and resolving claim disputes.
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5.6.7
Procedures
5.6.7-A.
Prior to filing an initial claim dispute
All behavioral health providers are encouraged to seek
informal resolution of a concern by first contacting the appropriate
entity responsible for the decision. For concerns regarding claims,
it is important for providers to understand why the claim was denied
before initiating a claim dispute. Denied claims may be the result
of filing errors or missing supporting documentation, such as an
explanation of benefits (EOB) or an invoice. Resubmitting claims
with the requested information or corrections can result in resolution
of the issue and full payment of the claim.
PM Attachment 5.6.1 identifies contact persons at the
RBHA and ADHS/DBHS that can assist with the informal resolution
of a decision.
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5.6.7-B.
Process for initiating a claim dispute to the RBHA
If an issue is unable to be resolved informally, behavioral
health providers may dispute the decision by filing a written claim
dispute. For all provider claim disputes related to decisions of
a RBHA, the provider must file the claim dispute with the RBHA.
See
PM
Attachment 5.6.1 for information regarding where to
submit a claim dispute.
What does
a written claim dispute include?
It is important for providers to ensure the claim dispute contains
all required information and is filed within the required timeframes.
Failure to do so will result in the denial of the claim dispute.
The claim dispute
submitted must contain:
- A brief
statement of the factual and legal basis for the dispute; and
- A statement
of the relief requested.
What are
the timeframes for initiating a claim dispute?
The claim dispute must be filed within the following established
timeframes:
- Within 60
days of the date of notice advising that a sanction will be imposed,
or
- For a denial
of a claim for payment, or, nonpayment of a claim, within:
- 12 months
of the date of delivery of the service; or
- 12 months
after the date of eligibility posting; or
- Within 60
days after the date of the denial of timely claim submission,
whichever is later.
How is time
computed?
A written claim dispute is considered filed when it is received
by the RBHA established by a date stamp or other record of the receipt.
Behavioral health providers must use the following methodology in
computing any period of time described in this section:
- Computation
of time for calendar day begins the day after the act, event or
decision and includes all calendar days and the final day of the
period. If the final day of the period is a weekend or legal holiday,
the period is extended until the end of the next day that is not
a weekend or a legal holiday.
What happens
after a provider files a claim dispute with the RBHA?
Within five days of receiving the claim dispute, the RBHA will notify
the provider in writing that:
- The claim
dispute has been received;
- The claim
dispute will be reviewed; and
- A decision
will be issued within 30 days of receipt of the claim dispute
unless an extension has been agreed upon.
It is possible
that a RBHA will determine that it is not the appropriate entity
to process the claim dispute. This can happen when the RBHA determines
that it is not responsible for the denial or non-payment of the
disputed claim or imposition of a sanction.
If the RBHA
determines that it is not responsible for the decision, the claim
dispute and all documentation will be sent immediately to the appropriate
entity as well as a copy of the transmittal and all documentation
to the provider that initiated the claim dispute.
How long
does the RBHA have to make a decision?
A decision on the claim dispute will be made by the RBHA within
30 days of receipt of the claim dispute, unless the RBHA and the
provider both agree, in writing, to a longer period. To request
an extension of the 30-day timeframe, the provider must submit to
the RBHA, prior to the expiration of the original time limit, a
written request including the reasons for the extension and a proposed
new timeframe that does not unreasonably postpone final resolution
of the matter. A representative of the RBHA may also request an
extension. In either case, the provider and the RBHA must agree
to the extension in writing. The decision to grant a request for
extension is made by the RBHA Director.
How will
a provider be informed of the claim dispute decision?
A written final decision, referred to as a Notice of Decision, will
be hand delivered or sent by certified mail to the provider by the
RBHA. The final decision letter will include a statement of the
nature of the claim dispute and the issues involved and will:
- Approve
or deny the claim for payment; or
- Affirm or
reverse the denial, in whole or in part; or
- Affirm or
reverse the sanction, in whole or in part; and
- Include the
date of the decision; and
- Include a
statement of the reasons for the decision and the statutes, rules
and policies involved; and
- Include a
statement that a provider dissatisfied with the decision may request
an administrative hearing by filing a request with the ADHS/DBHS
Office of Grievance and Appeals within 30 days of receipt of the
decision. Included with the statement is a description of the
provider’s right to request an informal settlement conference.
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5.6.7-C.
Administrative hearing process for claim dispute decisions made
by the RBHA
If the provider is dissatisfied with the RBHA Notice of
Decision, the provider may request an administrative hearing by
filing, in writing, a request with the ADHS/DBHS Office of Grievance
and Appeals. See
PM
Attachment 5.6.1 for contact information and where
to submit a request for an administrative hearing.
What are
the timeframes for requesting an administrative hearing?
The provider’s request for a hearing must be filed in writing
and received by ADHS/DBHS within 30 calendar days of the date of
receipt of the RBHA claim dispute decision. A written request for
hearing is considered filed when received by ADHS/DBHS Office of
Grievance and Appeals established by a date stamp or other record
of receipt..
What does
a request for administrative hearing include?
In filing the request for an administrative hearing to ADHS/DBHS,
the provider must include:
- Provider
name, address and the ADHS/DBHS docket number;
- The issue
to be determined at the administrative hearing ; and
- The factual
and legal basis for the request for administrative hearing.
What happens
after a provider files a request for administrative hearing with
ADHS/DBHS?
Upon receipt of a request for hearing, the ADHS/DBHS Office of Grievance
and Appeals will schedule an administrative hearing at the State
Office of Administrative Hearings. An administrative law judge will
conduct the administrative hearing within 60 days after the request
is filed and will issue a written recommended decision to the ADHS
Director within 20 days after the hearing is completed. The ADHS
Director will issue a final decision within 30 days after receiving
the administrative law judge’s recommended decision.
What options
exist following the ADHS Director’s decision?
The provider may appeal a final administrative decision as follows:
- For claim
disputes involving Title XIX and XXI services, the provider has
the option of filing a written notice of appeal of the ADHS Director’s
final decision to the Arizona Health Care Cost Containment System.
This appeal must be filed with the ADHS Office of Administrative
Counsel within 30 calendar days after service of the ADHS Director’s
decision;
- File a motion
for rehearing with the ADHS Director within 30 days after service
of the ADHS Director’s decision; or
- For final
administrative decisions, file a petition for judicial review
with the Arizona Superior Court within 35 days after service of
the ADHS Director’s decision.
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5.6.7-D.
Process for initiating a claim dispute to ADHS/DBHS
If an issue is unable to be resolved informally, behavioral
health providers may file a written claim dispute. For all claim
disputes related to decisions of ADHS/DBHS, the provider must file
the claim dispute with ADHS/DBHS. See
PM
Attachment 5.6.1 for information regarding where to
submit a claim dispute.
What does
a claim dispute include?
It is important for providers to ensure the claim dispute contains
all required information and is filed within the required timeframes.
Failure to do so will result in the denial of the claim dispute.
The claim dispute
submitted must contain:
- A brief
statement of the factual and legal basis for the claim dispute;
and
- A statement
of the relief requested;
What are
the timeframes for initiating a claim dispute?
The claim dispute must be filed within the following established
timeframes:
- Within 60
days of the notice advising that a sanction will be imposed, or
- For a denial
of a claim for payment (in whole or in part), or, nonpayment of
a claim, within:
- 12 months
of the date of delivery of the service; or
- 12 months
after the date of eligibility posting; or
- Within 60
days after the date of the denial of timely claim submission,
whichever is later.
How is time
computed?
A written claim dispute is considered filed when it is received
by the ADHS/DBHS established by a date stamp or other record of
receipt. Behavioral health providers must use the following methodology
in computing any period of time described in this section:
- Computation
of time for calendar day begins the day after the act, event or
decision and includes all calendar days and the final day of the
period. If the final day of the period is a weekend or legal holiday,
the period is extended until the end of the next day that is not
a weekend or a legal holiday.
What happens
after a provider files a claim dispute with ADHS/DBHS?
Within five days of receiving the claim dispute, ADHS/DBHS will
notify the provider in writing that:
- The claim
dispute has been received;
- The claim
dispute will be reviewed; and
- A decision
will be issued within 30 days of receipt of the claim dispute.
It is possible
that ADHS/DBHS will determine that it is not the appropriate entity
to process the claim dispute. This can happen when ADHS/DBHS determines
that it is not responsible for the denial or non-payment of the
disputed claim or imposition of a sanction.
If ADHS/DBHS
determines that it is not responsible for the claim dispute, the
claim dispute and all documentation will be sent immediately to
the appropriate entity as well as a copy of the transmittal and
all documentation to the provider that initiated the claim dispute.
How long
does ADHS/DBHS have to make a decision?
A final decision on the claim dispute will be made by ADHS/DBHS
within 30 days of receipt of the claim dispute, unless ADHS/DBHS
and the provider both agree, in writing, to a longer period. To
request an extension of the 30-day timeframe, the provider must
submit to ADHS/DBHS, prior to the expiration of the original time
limit, a written request including the reasons for the extension
and a proposed new timeframe that does not unreasonably postpone
final resolution of the matter. A representative of ADHS/DBHS may
also request an extension. In either case, the provider and ADHS/DBHS
must agree to the extension in writing. The decision to grant a
request for extension is made by the ADHS Director or their designee.
How will
a provider be informed of the claim dispute decision?
A written final decision, referred to as a Notice of Decision, will
be hand delivered or sent by certified mail to the provider by ADHS/DBHS.
The final decision letter will include a statement of the nature
of the claim dispute and the issues involved and will:
- Approve
or deny the claim for payment; or
- Affirm or
reverse the denial, in whole or in part; or
- Affirm or
reverse the sanction, in whole or in part; and
- Include
the date of the decision;
- Include
a statement of the reasons for the decision and the statutes,
rules and policies involved; and
- Include
a statement that a provider dissatisfied with the decision may
request an administrative hearing by filing a request with the
ADHS/DBHS Office of Grievance and Appeals within 30 days of receipt
of the decision. Included with the statement is a description
of the provider’s right to request an informal settlement
conference.
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5.6.7-E.
Administrative hearing process for claim dispute decisions made
by ADHS/DBHS
If the provider is dissatisfied with the ADHS/DBHS Notice
of Decision, the provider may request an administrative hearing
by filing, in writing, a request with the ADHS/DBHS Office of Grievance
and Appeals. See
PM
Attachment 5.6.1 for contact information and where
to submit a request for an administrative hearing.
What are
the timeframes for requesting an administrative hearing?
The provider’s request for a hearing must be filed in writing
and received by ADHS/DBHS within 30 calendar days of the date of
receipt of the ADHS/DBHS Notice of Decision. A written request for
hearing is considered filed when received by ADHS/DBHS Office of
Grievance and Appeals established by a date stamp or other record
of receipt.
What does
a request for administrative hearing include?
In filing the request for an administrative hearing to ADHS/DBHS,
the provider must include:
- Provider
name, address and the ADHS/DBHS docket number;
- The issue
to be determined at the administrative hearing; and
- The factual
and legal basis for the request for administrative hearing.
What happens after a provider files a request for administrative
hearing with ADHS/DBHS?
Upon receipt of a request for hearing, the ADHS/DBHS Office of Grievance
and Appeals will schedule an administrative hearing at the State
Office of Administrative Hearings. An administrative law judge will
conduct the administrative hearing within 60 days after the request
is filed and will issue a written recommended decision within 20
days after the hearing is completed. The ADHS Director will issue
a final decision within 30 days after receiving the administrative
law judge’s recommended decision.
What options
exist following the ADHS Director’s decision?
The provider may appeal a final administrative decision as follows:
- For claims
disputes involving Title XIX and XXI services, the provider has
the option of filing a written notice of appeal of the ADHS Director’s
final decision to the Arizona Health Care Cost Containment System.
This appeal must be filed with the ADHS Office of Administrative
Counsel within 30 calendar days after service of the ADHS Director’s
decision;
- File a motion
for rehearing with the ADHS Director within 30 days after service
of the ADHS’ Director decision; or
- For final
administrative decisions, file a petition for judicial review
with the Arizona Superior Court within 35 days after service of
the ADHS Director’s decision.
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5.6
Provider Claims Disputes
Last Revised: 04/27/2006
Effective Date: 10/01/2006
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