Reference Guide: Appeals/Reconsiderations vs. Corrected Claims
The purpose of an appeal is to
- dispute the decision of a processed claim and/or
- request a review of processed claims or dispute and/or
- request a post-service denial of prior authorization.
The purpose of a resubmitted/corrected claim is to submit a change in claims billing from what was submitted with the original first-time claim.
A resubmitted claim is not the same as a reconsideration or appeal of a claim. The following is a full overview of the criteria and submission process for both an Appeal/Reconsideration and a Resubmitted/Corrected Claim.
Appeals/Reconsiderations
Process note: Appeals and Reconsiderations are identical processes operationally, and are referred to as an "appeal" for providers outside of Meridian's network, but are often referred to as a "reconsideration" for in-network Meridian providers.
The purpose of an appeal is to dispute the decision of a processed claim and/or request a review of processed claims or dispute and/or request a post-service denial of prior authorization.
- Post-Service Provider Appeal: An appeal of services that were denied or reduced because they did not meet specific criteria, policy or guideline and have a denied authorization on file. For example, the provider disagrees with a determination made by Meridian, such as combining two stays as a 15-day readmission. In this case, the provider should send additional information (such as medical records) that support the provider’s position.
- Administrative Appeal: An appeal by a provider of a claim/service denied for failure to authorize services according to timeframe requirements. In this case, the provider must explain the circumstances and why the provider feels an exception is warranted in that specific case.
Process
Providers may submit a post-service appeal in one of three ways:
- Login to the Provider Portal to submit an appeal. This is the preferred method for a quicker turnaround time.
- Via mail by filling out the Appeal Cover Letter form and sending documentation to support your position, such as medical records, to the following address:
Meridian Attn: Appeals Department
PO Box 8080
Farmington, MO 63640-8080 - Via fax by filling out the Appeal Cover Letter form and sending documentation to support your position, such as medical records, to 833-592-0658
Time Frame
Provider appeals must be submitted within 365 days of the date of service or 120 days of the EOP for Medicaid and Commercial Products whereas it’s 180 days for MMP and Medicare Advantage or 120 days of the EOP, whichever is later, provided the initial claim was submitted timely (unless specified otherwise within the provider contract).
Response to Post-Service Provider Appeals Meridian typically responds to a Post-Service Provider Appeal within 30 calendar days from the date of receipt. Providers will receive a letter with Meridian’s decision and rationale. There is only one level of appeal available for Post-Service Provider Appeal reviews. All appeal determinations are final.
Corrected Claim
The purpose of a resubmitted/corrected claim is to submit a change in claims billing from what was submitted with the original first-time claim. A resubmitted claim is not the same as a reconsideration or appeal of a claim.
Process
Corrected claims can be submitted in one of three ways:
- Electronic claims submission
- Through Availity
- Via mail to the following address:
Meridian Attn: Claims Department
PO Box 8080
Farmington, MO 63640-8080
If you are re-submitting a claim for a status or a correction, please indicate “Status” or “Claims Correction” on the claim.
If you are replacing or voiding/cancelling a UB-04 claim, please use appropriate bill type of 137 or 138. If you are replacing or cancelling a CMS 1500 claim, please complete box 22. For replacement or corrected claim, enter resubmission code 7 in the left side of item 22 and enter the original claim number of the claim you are replacing in the right side of item 22.
If submitting a void/cancel claim, enter resubmission code 8 on the left side of item 22 and enter the original claim number of the paid claim you are voiding/cancelling on the right side of item 22. If you do not follow these corrected claim form submission processes the claim will deny a duplicate claim submission.
Time Frame
Corrected claims must be submitted within 120 days from the date of the original explanation of payment or denial for Commercial and MMP products whereas it’s 180 days for Medicare Advantage. Medicaid requires corrected claims to be submitted 365 days from date of service or 120 days from the last date of adjudication/ remit whichever is later.
Provider Relations Inquiry Form
Additionally, the Meridian Provider Relations Inquiry Form can be utilized to escalate concerns such as:
- Review of a claim that you would like to have further reviewed to confirm that the first claim submission was paid correctly / incorrectly
- If disagreement persists after an appeal has been reviewed