Provider Dispute Resolution Process for Western & Southwest
(Colorado Only) Regions and Oregon and Washington |
Published: October, 2001
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Expedited Appeals
Routine Appeals
PBH provides a process for providers to appeal claims payment and treatment authorization determinations made by PBH. These appeals are reviewed in a timely and impartial manner and PBH makes every effort to resolve such matters in a period of not more than thirty (30) business days (60 calendar days for Colorado providers).
This process exists to resolve disputes that may arise between a provider and PBH. In addition to this process, or as an alternative to this process, providers may also serve as member advocates or member representatives in the PBH Member Appeals Process. This participation must be designated by the member or legal guardian.
Expedited Appeals
PBH will expedite the review of any appeals involving PBH denials of treatment authorization for requests for facility-based care. Expedited appeals may be initiated telephonically, however it will be necessary for PBH to request copies of all relevant medical records and/or other clinical information. Expedited appeals are reviewed within the following timeframe:
- Within twenty-four (24) hours of receipt of all information necessary to render a determination
Determinations will be communicated by telephone and in writing to the provider(s) and member/family within twenty-four (24) hours of the completion of the review.
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Routine Appeals
Appeals must be initiated in writing by providers, or provider representatives, within eighteen (18) months of the date(s) of service. Appeals received after this time will not be considered for payment.
Appeals for the Western Region may be sent to:
PacifiCare Behavioral Health of California, Inc.
P.O. Box 55307
Sherman Oaks, CA 91413-0307
Attn: Appeals Department
Appeals for the Oregon and Washington may be sent to:
PacificCare Behavioral Health, Inc.
P.O. Box 3009
Hillsboro, OR 97123-3009
Attn: Provider Appeals
Appeals for Colorado may be sent to:
PacificCare Behavioral Health - Southwest
5001 LBJ Freeway, Suite 600
Dallas, TX 75244
Attn: Appeals Department
Upon receipt of an appeal, a PBH Appeals Coordinator will ensure that all information necessary to render a determination (i.e. clinical documentation) is possessed by PBH. The appeal will then be reviewed by a PBH Medical Director (or designee). The PBH Appeals Coordinator will send written notice of the appeal determination to the provider within thirty (30) business days of PBH's receipt of the appeal (60 days for Colorado Providers).
If the provider is dissatisfied with the outcome of the initial appeal, he/she may dispute the initial determination by submitting a written request for a second level appeal review. The request must be received by PBH within thirty (30) business days of the provider's receipt of the first level appeal determination (PBH considers the letter to be "received" by the provider seven (7) days after the letter is sent by PBH). The request should be sent to the above address. If the appeal involves a PBH denial of treatment authorization, the attending physician or treating provider must provide a letter documenting the clinical rationale for his/her appeal.
Upon receipt of a second level appeal, a PBH Appeals Coordinator will ensure that all information necessary to render a determination (i.e. clinical documentation, letter from provider) is possessed by PBH. The appeal will then be reviewed by a PBH Medical Director (or designee). The PBH Appeals Coordinator will send written notice of the appeal determination to the provider within thirty (30) business days of PBH's receipt of the appeal.
Please note that no single PBH Medical Director or other licensed behavioral healthcare professional is involved in more than one level of the appeal review process. Additionally, a PBH Medical Director or other licensed behavioral healthcare professional who issues an initial denial of treatment authorization will not be involved at either level of the appeal review process. All appeal determinations involving the Medical Necessity or clinical appropriateness of behavioral health treatment are made by licensed behavioral healthcare professionals. The clinical criteria used in determining Medical Necessity are available upon request.
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