Appeals & Grievances Form
Presbyterian encourages providers/practitioners to file claims correctly the first time or, if time allows, resubmit the claim through the Provider CARE Unit to resolve an issue.
A provider/practitioner is encouraged to contact his/her Provider Services Coordinator to help clarify any denials or other actions relevant to the claim and to help with a possible resubmission of a claim with modifications.
Provider Appeal and Grievance Form
Remember, a provider/practitioner has one year (12 months) from the date of services to file an appeal regarding a claim denial, or the denial will be upheld as past the filing limit for initiating an appeal. Providers who are not contracted with Presbyterian Medicare Lines of Business have 60 calendar days from the remittance notification date to file an appeal or the denial will be upheld as past the filing limit for initiating an appeal. When filing an appeal, a provider/practitioner must be able to show documentation that timely follow-up was conducted into the matter. Timely follow-up includes proof of contact with the plan, such as patient ledgers or copies of written communications.
When filing an appeal, please remember to document the reasons for your reconsideration request, and attach all supporting documentation for review of the issue. If the issue involves a claims denial appeal, and you previously submitted the claim electronically, please include a copy of the claim in question for review of your appeal. If the appeal is related to a claims coding matter, it is helpful to include supporting medical records, such as office notes and operative reports, if applicable.
Please fill in the following form, and press the Submit button to send your inquiry to the Appeals and Grievance Department for review. We will reply as soon as we have researched the appeal/grievance for you.
Provider Grievances for Interagency Benefits Advisory Committee (IBAC), Fully-Insured and Commercial Plans
Providers have the right to present oral or documentary evidence to a Presbyterian committee review panel responsible for the substantive area addressed by the concern. If the grievance raises a quality-of-care concern the panel will include a New Mexico-licensed medical professional who practices in the general area of concern. Presbyterian will issue a decision to the provider pursuing a grievance within 45 calendar days after the committee has obtained all information concerning the provider’s grievance. No person with a conflict of interest will participate in a decision to resolve a grievance. For a list of the applicable regulations, please refer to the Applicable Appeal and Grievance Regulations.Regulations Relevant to Appeal and Grievance Policies and Procedures
All information is required for us to process your appeal/grievance.
Providers who are not contracted with Presbyterian Medicare Lines of Business must include a signed Waiver of Liability form with any appeal.
Please complete the form below
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