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Filing an Appeal, Reconsideration or Grievance

If you wish to dispute a coverage decision, you may request a reconsideration or file an appeal or grievance by following the processes detailed below.

Before you file an appeal, reconsideration or grievance, please be aware that claim denials or authorization requests may often be denied because of insufficient or incorrect information. Members can seek assistance by contacting our Member Services department by phone at (443) 451-4979 or by email at client_advocacy@evergreenmd.org. Providers can seek assistance by contacting our Provider Services department by calling (443) 475-0105 or emailing providers@evergreenmd.org.

Please note that this process is only for medical claims. To request a reconsideration of claims for prescription drugs, mental health or substance abuse, routine vision or pediatric dental services, please follow the instructions at this link.

RECONSIDERATIONS


A reconsideration is a request for Evergreen Health to review the coverage decision. This can be filed by the member, the member’s representative or a health care provider. A reconsideration is not an attempt to file a formal appeal.

If you believe that your claim has been denied in error, you may ask Evergreen Health to reconsider the claim. If necessary, you should provide additional documentation to support your claim.

Please complete the Claim Reconsideration Form and attach any additional documentation. This may be submitted to one of the following locations:

Evergreen Health
Attn: Claim Reconsiderations
3000 Falls Rd. Ste. 400
Baltimore, MD 21211
Fax: 888.975.1538
Email: providers@evergreenmd.org

Your reconsideration will be reviewed in order of receipt. If your reconsideration request is approved for a pre-receivership claim, you should receive an adjusted Explanation of Pending Payments (EOPP) or Explanation of Benefits and Rights (EOBR). If your reconsideration request is approved for a post-receivership claim, you should receive an adjusted Explanation of Payment (EOP) or Explanation of Benefits (EOB). If your reconsideration request is denied, Evergreen Health will follow up with you as to why your request was not approved.

APPEALS


An appeal is a formal protest of a coverage decision. This can be filed by the member, the member’s representative or a health care provider. Members and member representatives have up to 180 calendar days to submit an appeal, while providers have 90 working days to submit an appeal.

If your reconsideration request has been denied or you otherwise wish to appeal a denied claim, you may submit a claim appeal request to Evergreen Health. You should provide additional documentation to be considered during the appeal process.

Please complete the Post-Service Claim Appeal Form and attach any additional documentation. This may be submitted to one of the following locations:

Evergreen Health
Attn: Claim Reconsiderations
3000 Falls Rd. Ste. 400
Baltimore, MD 21211
Fax: 888.975.1538
Email: claimsappeals@evergreenmd.org

Your claim appeal will be reviewed in order of receipt, and the decision may take up to 60 working days. Within 30 calendar days of the decision, you will be notified of the outcome, as well as any subsequent steps that you can take if you are still dissatisfied.

TIMELY FILING DENIALS

In-network providers are required to submit claims on behalf of members to Evergreen Health within 180 calendar days of the date of service. All claims submitted after this period may be denied as untimely, and the member is not financially responsible for this denial.

If you have already received a timely filing denial but believe that you have already submitted sufficient proof of timely filing, please use the Claim Reconsideration form. If you have already received a timely filing denial and wish to submit new or additional proof of timely filing, please use the Claim Appeal form.

If your claim is untimely and you have not yet received a claim denial, please submit your claim, along with supporting documentation with the Provider Timely Filing Review form. This may be submitted to one of the following locations:

Evergreen Health
Attn: Claim Reconsiderations
3000 Falls Rd. Ste. 400
Baltimore, MD 21211
Fax: 888.975.1538
Email: providers@evergreenmd.org

Your timely filing review form will be reviewed in order of receipt. You will be notified of the outcome on a forthcoming EOP or EOPP.

If covered services were furnished by an out-of-network provider,

While out-of-network providers may submit claims on our members’ behalf, members are ultimately responsible for submitting timely claims for care. Members who are enrolled in 2016 plans have 180 calendar days from the date of service to submit timely claims, while members who are enrolled in 2017 plans have up to one year from the date of service.

GRIEVANCES

A grievance is a formal dispute of an adverse decision, which is a determination that a covered health care service was not medically necessary, appropriate or efficient. This can be filed by the member, the member’s representative or a health care provider. Please note that an administrative denial for failure to authorize services is not an adverse decision.

If you wish to file a grievance regarding an adverse decision, you must submit your request in writing. Please submit your request, along with any additional clinical documentation that supports the medical necessity, appropriateness or efficiency of the service, to one of the following locations:

Evergreen Health
Attn: Clinical Grievances
3000 Falls Rd. Ste. 400
Baltimore, MD 21211
Fax: 844.414.8860
Email: clinicalservices@evergreenmd.org

Your grievance will be reviewed in order of receipt, and the decision may take up to 30 working days. Evergreen Health may contact you for additional information that is needed to make the grievance decision, which may extend the time frame to make the decision. Once Evergreen Health makes its grievance decision, you will be notified of the outcome, as well as any subsequent steps that you can take if you are still dissatisfied.

QUALITY OF CARE

Evergreen Health also investigates complaints from members related to the quality of care and service that was provided by health care providers in our network. In response to a quality of care complaint, Evergreen Health will contact the provider in question for additional information. At the conclusion of our investigation, Evergreen Health will advise the member and provider in question about the findings and resolution.

If you wish to file a quality of care complaint, please send your written complaint to:

Evergreen Health
Attn: Clinical Services Department
3000 Falls Rd. Ste. 400
Baltimore, MD 21211

HEALTH EDUCATION AND ADVOCACY UNIT

There is help available to you if you wish to dispute the decision about payment for health care services. The Health Education and Advocacy Unit can help you, your representative and your health care provider prepare an appeal to file under the internal appeal procedure. This unit can also attempt to mediate a resolution to your dispute. You may contact the Health Education and Advocacy Unit of the Maryland’s Consumer Protection Division at:

Health Education and Advocacy Unit
Consumer Protection Division
Office of the Attorney General
200 St. Paul Place, 16th Floor
Baltimore, MD 21202
Phone: 410-528-1840 or 1-877-261-8807
Fax: 410-576-6571
Email: heau@oag.state.md.us

You may also contact Health Education and Advocacy Unit on their website by following this link.