Claim Adjustment/Appeal Guidelines

Providers typically have 12 months from the processed date to submit the initial request. The 12-month timeframe does not apply to claims denied for lack of prior authorization or medical records requests from the health plan. For these two scenarios, providers must submit the initial request within 60 days of the process date (see Time Frames below for additional information).

Except as stated above, providers will be allowed two requests, an adjustment/initial review request and an appeal request. Medica's response to the appeal will be the final decision and further administrative review of the issue will not be available. If three or more requests are received, Medica will reject these requests as all adjustment requests/appeals have been exhausted.

Adjustments/Refunds

Although every effort is made to ensure accurate claim processing, occasionally a claim (or group of claims) may be processed incorrectly. It then becomes necessary to adjust the claim(s). Following are some examples of when a claim may need to be adjusted:

Provider is underpaid or overpaid
Incorrect provider is reimbursed
Medica claim audit procedure uncovers an error, duplicate payments, bundling errors, etc.
Medica staff receives new information about a claim or the agreement under which it was processed
Reconsideration/review of a decision made on the original claim submitted

The provider or Medica may determine a need for a claim adjustment. Medica may perform necessary adjustments without requesting additional information from the network provider. The provider will see the adjustment on the Provider Remittance Advice (PRA)/Electronic Remittance Advice (ERA).

When network providers identify the need for claim adjustment(s)/initial review, Medica encourages providers to submit a corrected or void claim electronically via their clearinghouse in accordance with 837 submission guidelines. Providers may also complete the Claim Adjustment/Appeal Request Form as necessary. See time frames listed below. Send the completed form and supporting documentation as appropriate to Medica at the address listed on the form.

Claim Adjustment/Appeal Request Form

If a previously submitted claim needs to be eliminated in its entirety, provider should submit a void claim instead. Examples of when a claim may need to be voided include:

Incorrect provider, patient or payer
Incorrect insured and statement period on an institutional claim
Patient did not want insurer to be billed for services

Appeals

An appeal will be accepted after the above adjustment request/initial review process has been completed. For claims with a prior adjustment request/initial review, providers can request an appeal by adding a rationale in the Adjustment and Appeal Request Form and attaching additional documentation not previously submitted that will support the rationale. Submit form and documentation to the appropriate address on the form.

NOTE: An appeal will only be accepted within 60 days after a claim denial for lack of prior authorization or a request for medical records.

Requests for adjustment or appeal involving a decision based on medical necessity will be reviewed by clinical staff or a physician.

Adjustment/Appeal Time Frames

Routine Adjustments/Appeals

Requests for claim adjustments and or appeals on underpayments must be made within 12 months of the reimbursed date. If a request for more information is received, the corrected claim or additional information must be resubmitted and received at the designated claims address within 60 days of the date on the response letter from Medica. There is also a 60-day timeframe from the date of the denial on the provider remittance advice/electronic remittance advice (PRA/ERA) for submitting an appeal for lack of prior authorization when one is required by Medica.

Adjustments Due to Coordination of Benefits, Subrogation, Duplicate Claims, Fraud or Abuse, and Retroactive Eligibility Determinations

The 12-month adjustment time limit shall not apply to claims adjusted due to:

payments subject to Coordination of Benefits recovery;
payments subject to subrogation recovery;
duplicate claims payments;
adjustments due to fraud or abuse, including without limitation adjustments due to determination by Medica that provider was overpaid as a result of erroneous, abusive or fraudulent billing; and
retroactive terminations due to a retroactive determination of a Member's eligibility for a government program or subsidy, and Medica may make such adjustments at any time and such adjustments are not subject to the time frame set forth above.

Dispute Resolution

A network provider may dispute any payment of a claim through the Claim Adjustment/Appeal Request process (form found here). In the event the dispute is not resolved through the claim adjustment/appeal request process, timely written notice outlining the dispute must be supplied by the party seeking to pursue the dispute. The parties will attempt in good faith to resolve the dispute promptly through discussions and negotiations with each other. If the dispute remains unresolved, either party may initiate litigation of such dispute.

Additional Resources

Providers are able to obtain additional information, including downloadable forms, under the Adjustment and Resubmission Processes section of Claims Tools.

REV 9/2022