Claims, Appeals and Complaints

Disclaimer
Magellan contracts with Change Healthcare to process claims payments, including Provider Explanation of Payment (EOP) documents. Due to Change Healthcare’s cybersecurity incident, Magellan is generating this standard Provider Explanation of Payment document to generate payments to providers as quickly as possible. We recognize that EOP information, including appeal and reconsideration rights, differs based on the member’s health plan. Therefore, EOP information, including the specific appeal/reconsideration language for the member’s respective plan can be found on this page: https://provider.magellanhealthcare.com/claims-appeals-and-complaints.

CA markets: If you suspect Fraud or Abuse involving health benefits, please call the toll-free California Fraud Hotline at 1-800-424-6074.

All Other markets: If you suspect fraud or abuse involving health benefits administered by Magellan, please call our toll-free hotline at 1-800-755-0850 or contact us by email siu@magellanhealth.com . For all other calls and questions, please contact the customer service number located on your plan specific statement.

Endorsing or depositing a paper check you receive from any Federal or State funds that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.

What's on this page?

Advocate Physician Partners Commercial
Advocate Physician Partners Medicare HMO
Advocate Physician Partners Medicare HMO/POS
Advocate Physician Partners Medicare Premiere HMO/POS
Blue Cross Blue Shield of Texas – Blue Advantage
Blue Cross Blue Shield of Texas – Medicaid Chip
Blue Cross Blue Shield of Texas – Medicaid Star
Blue Cross Blue Shield of Texas – Medicaid Star Kids
Blue Cross Blue Shield of Texas – Medicare Advantage (HMO)
Blue Cross Blue Shield of Texas – Medicare DSNP
Blue Shield of California – DMHC Plans
Blue Shield of California – DOI Plans
Blue Shield of California – Medicare
Connect Nevada: Strengthening Youth, Empowering Families
Dell Childrens Health Plan Chip
Dell Childrens Health Plan Star
Devoted Health Plan (AL, CO, FL, NC & OH)
Devoted Health Plan (AZ, HI, IL, OR, PA, SC, TN & TX)
Doctors Health Plans
Health Partners of Philadelphia dba Jefferson Health Plans (Commercial)
Health Partners of Philadelphia dba Jefferson Health Plans (Medicare)
Health Partners of Philadelphia Medicaid
Health Plan of San Mateo
Louisiana Coordinated System of Care (CSOC)
Michelin North America
NECA IBEW Family Medical Care Plan
New Orleans Employers International Longshoreman's Association (ILA)
Nissan North America
Positive Healthcare California Medicaid
Positive Healthcare California Medicare and Dual
Positive Healthcare Florida Medicare and Dual
Presbyterian Health Plan - Turquoise Care New Mexico and Dual
Presbyterian Health Plan Commercial
Presbyterian Health Plan Medicare
Sharp Health Plan Commercial
Sharp Health Plan Medicare
St Vincent USFHP
Yale Health Plan

Advocate Physician Partners Commercial

Customer Service Number: 1-888-363-8966 / TDD 711

Claims Address:
Magellan Behavioral Health Systems, LLC
PO Box 1959
Maryland Heights, MO 63043

Appeals:
Important Information about Your Appeal Rights

What if I don’t agree with this decision? Providers have the right to a formal appeal. For inquiries regarding this decision, please contact Magellan at 888-363-8966.

How do I file an appeal? As the provider acting on behalf of the member and with his /her consent, you have the right to request a review of any adverse determination regarding coverage or a payment decision within 60 days of receipt of this document. You may file an appeal by writing to:

Magellan Appeals
P.O. Box 1718
Maryland Heights, MO 63043

If the appeal is denied, you may be able to request an external independent review. An external independent review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness. You may submit a written request for an external review to the Department of Insurance, Office of Consumer Health Information, 320 West Washington Street, 4th Floor, Springfield, Illinois, 62767. The written request should be submitted within four (4) months of receipt of an adverse determination or final adverse determination and outline the reason(s) why the denial or payment decision should be changed, including specific, pertinent documentation that supports the need for and appropriateness of the services rendered. Include all medical records that apply to the service on the claim, and make sure to include the member’s name, member identification number and the date of service(s).

Advocate Physician Partners Medicare HMO

Customer Service Number: 1-888-363-8966 / TTY 1-800-424-0298

Claims Address:
Magellan Behavioral Health Systems, LLC
PO Box 1959
Maryland Heights, MO 63043

Appeals:
Contracted providers participating in provider network(s) for Medicare Advantage plans may request an appeal of a denial determination. Appeals must be submitted within 60 days of the date of this notice. You may file an appeal by writing to:

Magellan Health Services
Attention: Appeals
P.O. Box 1718 Maryland Heights, MO 63043

Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

Blue Cross Medicare Advantage
Appeals & Grievances
P. O. Box 4288 Scranton, PA 18505
Fax: 1-855-674-9185

Advocate Physician Partners Medicare HMO/POS

Advocate Physician Partners Medicare Premiere HMO/POS

Blue Cross Blue Shield of Texas – Blue Advantage

Customer Service Number: 1-888-291-2555

Claims Address:
MBC Health Providers of Texas, Inc.
P.O. Box 1289
Maryland Heights, MO 63043

Appeals:
For BCBSTX members, please see provider appeals guidelines below.

Reconsideration of Claims Payments
If this plan is a Medicare plan, Medicaid plan, other government-sponsored program or church-sponsored program, the appeal process below does not apply to this claim. You should call Magellan at 1-888-291-2555 with any questions.

We have reviewed your claim and have thoroughly considered the information submitted in support of your claim. If you would like to discuss this claim determination or have questions related to the member's benefit plan, such as deductibles, co-insurance, or co-payments, please contact Magellan at 1-888-291-2555.

An initial request by a provider or reconsideration of our claim payment determination must be submitted in writing and within the deadline identified below for the type of request to be made.

Claim Disputes
180 calendar days of the check date or "Run Date" on the Explanation of Payment/Explanation of Benefits of the claim(s) in dispute.

Over-payment Disputes
45 calendar days of your receipt of the written request for refund due to over-payment by Magellan.

Audited Payment Disputes
30 calendar days of your receipt of the written request for refund on an audited claim.

Your written request should include the member's name, group name (e.g., employer), member identification number, and any other identifying information, along with the issue and comments you would like to have considered. Please attach a copy of the relevant Explanation of Benefits/Explanation of Payment and/or other correspondence from Magellan as well as any additional documentation you would like us to review.

Address your written request to:

Magellan Health Services
Claims Appeals
P.O. Box 1718
Maryland Heights, MO 63043

Claims paid by Magellan Behavioral Health Systems, LLC on behalf of Blue Cross and Blue Shield of Texas

Texas law (28 TAC 11.506) requires that an HMO may not impose copayment charges that exceed fifty percent of the total cost of providing any single service to its enrollees. Your copayment may be reduced to ensure compliance with this regulation. If the copayment taken on this claim is less than you paid your provider, please contact your provider regarding a possible refund.

If you are a non-participating provider with Magellan and you disagree with the payment amount, you may be eligible to request mediation or arbitration for claims involving Blue Advantage HMO, Blue Advantage Plus HMO as well as MyBlue Health fully insured members. To learn more and submit a request, go to www.tdi.texas.gov. After you submit a complete request, you must notify Magellan at cceprivacyoffice@magellanhealth.com.

Blue Cross Blue Shield of Texas – Medicaid Chip

Customer Service Number: 1-800-327-7390

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 2154
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this document. You may file an appeal by writing to:

Magellan
P.O. Box 1718
Maryland Heights, MO 63043

Blue Cross Blue Shield of Texas – Medicaid Star

Customer Service Number: 1-800-327-7390

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 2154
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 120 days of receipt of this document. You may file an appeal by writing to:

Magellan
P.O. Box 1718
Maryland Heights, MO 63043

Texas Medicaid DPP increase included, if applicable.

Blue Cross Blue Shield of Texas – Medicaid Star Kids

Customer Service Number: 1-800-327-7390

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 2154
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 120 days of receipt of this document. You may file an appeal by writing to:

Magellan
P.O. Box 1718
Maryland Heights, MO 63043

Texas Medicaid DPP increase included, if applicable.

Blue Cross Blue Shield of Texas – Medicare Advantage (HMO)

Customer Service Number: 1-800-327-9251

Claims Address:
Blue Cross Medicare Advantage (HMO)
Magellan Healthcare
P.O. Box 1289
Maryland Heights, MO 63043

Appeals:
Contracted Providers: Participating in provider network(s) for Medicare Advantage plans may request a dispute review of a denial determination. Disputes must be submitted within 60 days of the date on this notice. You may file dispute by writing to:

Magellan Appeals
P.O. Box 1718
Maryland Heights, MO 63043
Fax No.: 1-888-656-5712
Phone No.: 1-800-805-9550

Non-Contracted Providers: If the amount paid by the plan for a covered service is less than the amount that would have been paid under original Medicare you may have the right to Dispute. Non-Contracted providers have 120 calendar days from the initial payment determination to file a payment dispute to:

Magellan Appeals
P.O. Box 1718
Maryland Heights, MO 63043
Fax No.: 1-888-656-5712
Phone No.: 1-800-805-9550

If the request for payment has been denied by the Medicare health plan that results in zero payment made to the non-contracted Medicare health plan provider, you may have the right to Appeal. Non-Contracted providers MUST file a written request within 60 calendar days from the remittance notification for reconsideration to: P.O. Box 4555, Scranton, PA 18505 or send via Fax: 1-855-895-4747.

Please provide the appeal request on company letterhead. Request must include a copy of the original claim form, remittance notification showing the denial and any clinical records and other documentation that supports the provider's arguments for reimbursement and a signed Waiver of Liability promising to hold the member harmless regardless of the outcome as required by the Centers for Medicare and Medicaid (CMS).

A copy of this Waiver of Liability is available at the following link:
https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/model-waiver-of-liability_feb2019v508.zip. Please mail all requested documents to P.O. Box 4555, Scranton, PA 18505 or send via Fax: 1-855-895-4747. If you have any questions regarding these forms, please contact our customer service department at 1-877-774-8592.

If the signed Waiver of Liability is not included, no action can be taken on the reconsideration until such signed Waiver of Liability is received. The time frame for acting on a reconsideration request commences when the properly signed Waiver of Liability form and other requested documentation is received. If the signed Waiver of Liability or the documentation is not received by the conclusion of the appeal time frame, the case will be dismissed.

Blue Cross Blue Shield of Texas – Medicare DSNP

Customer Service Number: 1-800-327-9251

Claims Address:
BCBS Texas Medicare DSNP
Magellan Healthcare
P.O. Box 1289
Maryland Heights, MO 63043

Appeals:
Contracted Providers: Participating in provider network(s) for Medicare Advantage plans may request a dispute review of a denial determination. Disputes must be submitted within 60 days of the date on this notice. You may file dispute by writing to:

Magellan Appeals
P.O. Box 1718
Maryland Heights, MO 63043
Fax No.: 1-888-656-5712
Phone No.: 1-800-805-9550

Non-Contracted Providers: If the amount paid by the plan for a covered service is less than the amount that would have been paid under original Medicare you may have the right to Dispute. Non-Contracted providers have 120 calendar days from the initial payment determination to file a payment dispute to:

Magellan Appeals
P.O. Box 1718
Maryland Heights, MO 63043
Fax No.: 1-888-656-5712
Phone No.: 1-800-805-9550

If the request for payment has been denied by the Medicare health plan that results in zero payment made to the non-contracted Medicare health plan provider, you may have the right to Appeal. Non-Contracted providers MUST file a written request within 60 calendar days from the remittance notification for reconsideration to: P.O. Box 4555, Scranton, PA 18505 or send via Fax: 1-855-895-4747.

Please provide the appeal request on company letterhead. Request must include a copy of the original claim form, remittance notification showing the denial and any clinical records and other documentation that supports the provider's arguments for reimbursement and a signed Waiver of Liability promising to hold the member harmless regardless of the outcome as required by the Centers for Medicare and Medicaid (CMS).

A copy of this Waiver of Liability is available at the following link:
https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/model-waiver-of-liability_feb2019v508.zip. Please mail all requested documents to P.O. Box 4555, Scranton, PA 18505 or send via Fax: 1-855-895-4747. If you have any questions regarding these forms, please contact our customer service department at 1-877-774-8592.

If the signed Waiver of Liability is not included, no action can be taken on the reconsideration until such signed Waiver of Liability is received. The time frame for acting on a reconsideration request commences when the properly signed Waiver of Liability form and other requested documentation is received. If the signed Waiver of Liability or the documentation is not received by the conclusion of the appeal time frame, the case will be dismissed.

You have the right to request an Independent Review Entity (IRE) review of the dismissal to the independent entity contracted by CMS called Maximus Federal Services. Instruction for sending dismissals to Maximus Federal Services is in the Notice of Dismissal of Appeal Request.

Blue Shield of California – DMHC Plans

Blue Shield of California – DOI Plans

Customer Service Number: (877) 263-9952 TDD/TTY (800) 424-6004

Claims Address:
Human Affairs International of California
P O Box 710400
San Diego, CA 92171

Appeals:
Member appeal rights are described separately on the back of the Member’s Explanation of Benefits.

Special Rule for Providers of California Members of Blue Shield of California Life & Health Insurance company MHSA plans:

If you have questions about how your claim was processed, you should contact Blue Shield of California Life & Health Insurance Company MHSA plan Customer Service Department by calling 1-877-263-9952.

If you are not satisfied with the Customer Service Department response to your inquiry, you have the right to appeal or request reconsideration of a claim, to seek resolution of a billing determination, to contest a request for reimbursement of an overpayment of a claim within 30 days, or to address any other contract dispute within 365 days of the date of this statement.

For information on filing a provider dispute (including an appeal), log on to www.magellanhealth.com/provider Click “News & Publications”, then “Handbooks”, then “State-, Plan-, and EAP-specific Supplements”, then “California”, and then “Appendices - Claims
Settlement Practices and Dispute Resolution”. Or you can send your dispute in writing to:

Human Affairs International of California
P O Box 719002
San Diego, CA 92171-9002

If you suspect Fraud or Abuse involving health benefits, please call the toll-free California Fraud Hotline at 1-800-424-6074.

California Department of Insurance Review

The California Department of Insurance is responsible for regulating health insurance. The Department’s Health Claims Bureau has a toll-free number 1-800-927-HELP (4357) or TDD 1-800-482-4833 to receive complaints regarding health insurance from either the insured or his or her provider. If you have a complaint against your insurer, you should contact the insurer first and use their grievance process. If you need the Department’s help with a complaint or grievance that has not been satisfactorily resolved by the insurer, you may call the Department’s toll-free telephone number 8am - 5pm, Monday - Friday (excluding holidays). You may also submit a complaint in writing to: California Department of Insurance, Health Claims Bureau, 300 S. Spring Street, South Tower, Los Angeles, California 90013, or through the website http://www.insurance.ca.gov/01-consumers/101-help/

Blue Shield of California – Medicare

Customer Service Number: (877) 263-9952 TDD/TTY (800) 424-6004

Claims Address:
Human Affairs International of California
P O Box 710400
San Diego, CA 92171

Appeals:
Contracted providers-
Contracted providers participating in provider network (s) for Medicare Advantage plans do not have independent appeal rights. As the provider acting on behalf of the member and with his /her consent, you have the right to appeal. To exercise it, file the appeal in writing within 60 calendar days after the date of this notice. You may file an appeal by writing to:

Blue Shield of California
Medicare Appeals and Grievances Department
P.O. Box 272620
Chico, CA 95927-2640

Non-Contracted providers-
Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider ’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

Blue Shield of California
Medicare Appeals and Grievances Department
P.O. Box 272620
Chico, CA 95927-2640

If you suspect Fraud or Abuse involving health benefits, please call the toll-free California Fraud Hotline at 1-800-424-6074.

Connect Nevada: Strengthening Youth, Empowering Families

Customer Service Number: 1-833-396-4310; TTY 711

Claims Address:
Magellan Healthcare, Inc.
PO Box 1749
Maryland Heights, MO 63043

Appeals:
Magellan of Nevada Providers must submit requests for appeal within 60 calendar days of the date of this notice. Submit appeals and requests for reconsideration of a denial determination in writing to the address below, and include at a minimum: a summary of the appeal or reconsideration request, member’s name, member’s identification number, date of service(s), reason(s) why the denial should be reversed, and copies of related documentation and/or applicable medical records to support appropriateness of the services rendered.

Send appeals of behavioral health denials, appeals for requests for reconsideration for medical necessity or authorization issues, and all other claim inquiries to:

Connect Nevada: Strengthening Youth, Empowering Families
Attention: Nevada Appeals & Grievance Department
P.O. Box 34028, Reno, NV 89533
Fax: 1-888-656-5426

For more information regarding Magellan of Nevada provider complaint/grievance process, please visit
https://www.magellanhealthcare.com/magellan-of-nevada/for-providers/quality-management/complaint-grievance-process/

Dell Childrens Health Plan Chip

Customer Service Number: 1-800-424-1764

Claims Address:
Magellan Behavioral Health Systems, LLC.
PO Box 1325
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 120 days of receipt of this document. You may file an appeal by writing to:

Magellan
P.O. Box 1718
Maryland Heights, MO 63043

Texas Medicaid DPP increase included, if applicable

Dell Childrens Health Plan Star

Devoted Health Plan (AL, CO, FL, NC & OH)

Customer Service Number: 1-800-776-8684 TTY 711

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 1655
Maryland Heights, MO 63043

Appeals:
Contracted providers participating in provider network(s) for Medicare Advantage plans do not have independent appeal rights. The request for review of a denied claim may be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about
reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
P.O. Box 1718
Maryland Heights, MO 63043

As the provider acting on behalf of the member and with his/her consent, you have the right to appeal. To exercise it, file the appeal in writing within 60 calendar days after this notice. You may file an appeal by writing to:

HMO D-SNP plans:
Devoted Health, Inc
ATTN: Appeals & Grievances
PO Box 21327
Eagan, MN 55121

All other plans:
Devoted Health, Inc
ATTN: Appeals & Grievances
PO Box 21327
Eagan, MN 55121

Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

HMO D-SNP plans:
Devoted Health, Inc
ATTN: Appeals & Grievances
PO Box 21327
Eagan, MN 55121

All other plans:
Devoted Health, Inc
ATTN: Appeals & Grievances
PO Box 21327
Eagan, MN 55121

If your patient is a Medicaid / Qualified Medicare Beneficiary, review your records for any wrongfully collected deductible, coinsurance or copayment. This amount may be billed to a subsequent payor.

Devoted Health Plan (AZ, HI, IL, OR, PA, SC, TN & TX)

Customer Service Number: 1-800-776-8684 TTY 711

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 1655
Maryland Heights, MO 63043

Appeals:
Contracted providers participating in provider network(s) for Medicare Advantage plans do not have independent appeal rights. The request for review of a denied claim may be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
P.O. Box 1718
Maryland Heights, MO 63043

As the provider acting on behalf of the member and with his/her consent, you have the right to appeal. To exercise it, file the appeal in writing within 60 calendar days after this notice. You may file an appeal by writing to:

Devoted Health, Inc
ATTN: Appeals & Grievances
PO Box 21327
Eagan, MN 55121

Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

Devoted Health, Inc
ATTN: Appeals & Grievances
PO Box 21327
Eagan, MN 55121

If your patient is a Medicaid / Qualified Medicare Beneficiary, review your records for any wrongfully collected deductible, coinsurance or copayment. This amount may be billed to a subsequent payor.

DOCTORS HEALTH PLANS

Customer Service Number: 1-800-424-1734 TTY 711

Claims Address:
Doctor's HealthCare Plans, Inc
P.O. Box 1916
Maryland Heights, MO 63043

Appeals:
Contracted INN providers- participating in provider network(s) for Medicare Advantage plans do not have independent appeal rights. The request for review of a denied claim may be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
P.O. Box 1718
Maryland Heights, MO 63043

Non-Contracted providers- pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

Doctor's HealthCare Plans, Inc
Attention: Appeals & Grievances Coordinator
2020 Ponce de Leon Blvd, Suite PH 1
Coral Gables, FL 33134
Fax: (786) 578-0293

Health Partners of Philadelphia dba Jefferson Health Plans (Commercial)

Customer Service Number: 1-800-424-3706 / TTY 1-800-424-3703

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 1869
Maryland Heights, MO 63043

Appeals:
Contracted INN providers -
Contracted providers can request for review of a denied claim by submitting in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial and any clinical records and other documentation that supports the provider ’s disagreement about reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
PO BOX 1718
Maryland Heights, MO 63043

As the provider acting on behalf of the member and with his/her consent, you have the right to appeal. To
exercise it, file the appeal in writing within 60 calendar days after this notice. You may file an appeal by writing to:

Jefferson Health Plans
Attn: Complaints, Grievances & Appeals Unit
1101 Market Street, Suite 3000
Philadelphia, PA 19107

Non-contracted providers -
Non-contracted providers can request for reconsideration of a denied claim by submitted in writing and
should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement for
reimbursement. You may file an appeal (request for reconsideration) in writing to:

Jefferson Health Plans
Attn: Complaints, Grievances & Appeals Unit
1101 Market Street, Suite 3000
Philadelphia, PA 19107

Health Partners of Philadelphia dba Jefferson Health Plans (Medicare)

Customer Service Number: 1-800-424-3706 / TDD 1-800-424-3703

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 1869
Maryland Heights, MO 63043

Appeals:
Contracted INN providers -
Contracted provider participating in provider network(s) for Medicare Advantage plans do not have independent appeal rights. The request for review of a denied claim may be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial and any clinical records and other documentation that supports the provider ’s disagreement about reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
PO BOX 1718
Maryland Heights, MO 63043

As the provider acting on behalf of the member and with his/her consent, you have the right to appeal. To exercise it, file the appeal in writing within 60 calendar days after this notice. You may file an appeal by writing to:

Jefferson Health Plans
Attn: Complaints, Grievances & Appeals Unit
1101 Market Street, Suite 3000
Philadelphia, PA 19107

Non-contracted providers -
Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliablity

The requests for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider ’s disagreement for reimbursement. You may file an appeal (request for reconsideration) in writing to:

Jefferson Health Plans
Attn: Complaints, Grievances & Appeals Unit
1101 Market Street, Suite 3000
Philadelphia, PA 19107

Health Plan of San Mateo

Customer Service Number: 1-800-424-4134

Claims Address:
Magellan Healthcare, Inc.
P.O. Box 710520
San Diego, CA 92171

Appeals:
Member appeal rights are described separately on the back of the Member's Explanation of Benefits.

Special Rule for Providers of California Members of Health Plan San Mateo:

Acting on your own behalf, you have the right to appeal or request reconsideration of a claim, to seek resolution of a billing determination, to contest a request for reimbursement of an overpayment of a claim, or to address any other contract dispute within 365 days of the date of this statement.

For information on filing a provider dispute (including an appeal), log on to www.magellanhealth.com/provider or www.magellanprovider.com. Click “News & Publications”, then “Handbooks”, then “State-, Plan-, and EAP-specific Supplements”, then “California”, and then “Appendices - Claims Settlement Practices and Dispute Resolution”.

If you suspect Fraud or Abuse involving health benefits, please call the toll-free California Fraud Hotline at 1-800-443-5704.

Health Plan of San Mateo
Attention: Claims Department
801 Gateway Boulevard
South San Francisco, CA 94080

Louisiana Coordinated System of Care (CSOC)

Customer Service Number: 1-800-424-4489 TDD 1-800-424-4416

Claims Address:
Magellan Behavioral Health Systems, LLC.
on Behalf of LA Medicaid CSoC
P.O. Box 1286
Maryland Heights, MO 63043

Appeals:
Medicaid providers must submit requests for appeal within 30 days of the date of this notice. Appeals and requests for reconsideration of a denial determination must be submitted in writing to the address identified below and include at a minimum: a summary of the appeal or reconsideration request, the member’s name, member’s identification number, date of service(s), reason(s) why the denial should be reversed and copies of related documentation and /or applicable medical records to support appropriateness of the services rendered.

Appeals of behavioral health denials, appeals for requests for reconsideration for medical necessity or authorization issues, and all other claim inquiries should be sent to:

Magellan Health Services of Louisiana
P.O. Box 83680
Baton Rouge, LA 70884

Michelin North America

Customer Service Number: 800-537-5221

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 2008
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this document. You may file an appeal by writing to:

Magellan Healthcare for Behavioral Health Appeals
P.O. Box 2128
Maryland Heights, MO 63043

NECA IBEW Family Medical Care Plan

Customer Service Number: 800-424-1602

Claims Address:
Magellan Behavioral Health Systems, LLC.
NECA/IBEW FAMILY MEDICAL CARE PLAN
P.O. Box 21914
Eagan, MN 55121

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this document. You may file an appeal by writing to:

Appeals Department
P.O. Box 2128
Maryland Heights, MO 63043
Fax: 888-656-3820

Your request should include the group name (e.g., employer) and patient’s name, identification number and other identifying information, along with the issue and comments you would like to have considered. Appeal rights include the right to submit additional records or information that might alter our determination. In addition, you may send a written statement and/or present evidence and testimony related to the claim and how you believe that it should be covered under your patient ’s plan.

You have up to 180 days to file an appeal with Magellan, and Magellan’s review should take no more than 30 days from the date your request is received. If Magellan denies your first level appeal, you may file a second level appeal to the FMCP Board of Trustees. You have 60 days to file a second level appeal by sending a letter, along with any additional information that you think will help a favorable decision to be made on your claim, to:

FMCP Board of Trustees
2400 Research Boulevard, Suite 500
Rockville, MD 20850

For certain types of claims, you may have the right to an external review by an independent review organization (IRO) following completion of all appeals with Magellan and the FMCP Board of Trustees. You must submit your request for an external review to the FMCP’s Benefit Office Department within four (4) months of your receipt of the Trustees’ final appeal decision on your claim. Contact the Benefit Office at 1-877-937-9602 with any questions on your rights to an external review by an IRO. If after completing this review process you remain unsatisfied, you have a right to bring a civil action under ERISA Section 502(a).

Additional Rights:

If you have any questions or for more information on claims and appeals procedures, you may contact Magellan at 1-800-424-1602.

New Orleans Employers International Longshoreman's Association (ILA)

Customer Service Number: 1-800-584-7459

Claims Address:
New Orleans Employers International
Longshoreman's Association
P.O. Box 1655
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this document. You may file an appeal by writing to:

Magellan Health Services
Magellan Appeals
P.O. Box 1718
Maryland Heights, MO 63043

Nissan North America

Customer Service Number: 1-833-812-2552 TTY 7-1-1

Claims Address:
Magellan Healthcare, Inc.
P.O. Box 2098
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this document. You may file an appeal by writing to:

Magellan Healthcare, INC
PO BOX 2128
Maryland Heights, MO 63043
FAX: 888 656 3820

Positive Healthcare California Medicaid

Customer Service Number: 800-480-4464 TTY 711

Claims Address:
AIDS Healthcare Foundation
P.O. Box 2246
Maryland Heights, MO 63043

Appeals:
Medicaid providers must submit requests for appeal within 90 days of the date of this notice. Appeals and requests for reconsideration of a denial determination must be submitted in writing to the address identified below and include at a minimum: a summary of the appeal or reconsideration request, the member’s name, member’s identification number, date of service(s), reason(s) why the denial should be reversed and copies of related documentation and/or applicable medical records to support appropriateness of the service rendered.

Appeals of behavioral health denials, appeals for requests for reconsideration for medical necessity or authorizations issues, and all other claim inquiries should be sent to:

PHP
P.O. Box 46160
6225 W. Sunset Blvd., 19th Floor
Los Angeles, CA 90046
800-263-0067

Positive Healthcare California Medicare and Dual

Customer Service Number: 800-480-4464 TTY 711

Claims Address:
AIDS Healthcare Foundation
P.O. Box 2246
Maryland Heights, MO 63043

Appeals:
Contracted INN providers- participating in provider network(s) for Medicare Advantage plans do not have independent appeal rights. The request for review of a denied claim may be submitted in writing within 365 days and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
P.O. Box 1718
Maryland Heights, MO 63043

As the provider acting on behalf of the member and with his /her consent, you have the right to appeal. To exercise it, file the appeal in writing within 60 calendar days after this notice. You may file an appeal by writing to:

PHP
P.O. Box 46160
6225 W. Sunset Blvd., 19th Floor
Los Angeles, CA 90028
Or Fax: (888) 235-8552

Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

PHP
P.O. Box 46160
6225 W. Sunset Blvd., 19th Floor
Los Angeles, CA 90028
Or Fax: (888) 235-8552

Positive Healthcare Florida Medicare and Dual

Customer Service Number: 1-800-480-4464 TTY 711

Claims Address:
AHF MCO of Florida, Inc
P.O. Box 2246
Maryland Heights, MO 63043

Appeals:
Contracted INN providers- participating in provider network(s) for Medicare Advantage plans do not have independent appeal rights. The request for review of a denied claim may be submitted in writing within 365 days and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file a claim dispute in writing to:

Magellan HealthCare
P.O. Box 1718
Maryland Heights, MO 63043

As the provider acting on behalf of the member and with his /her consent, you have the right to appeal.
To exercise it, file the appeal in writing within 60 calendar days after this notice. You may file an appeal by writing to:

PHP
P.O. Box 46160
6225 W. Sunset Blvd., 19th Floor
Los Angeles, CA 90028
Or Fax: (888) 235-8552

Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is
required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

PHP
P.O. Box 46160
6225 W. Sunset Blvd., 19th Floor
Los Angeles, CA 90046
Or Fax: (888) 235-8552

Presbyterian Health Plan - Turquoise Care New Mexico and Dual

Customer Service Number: 1-505-923-5200 or TDD 1-888-977-2333

Claims Address:
Presbyterian Health Plan
P.O. Box 25926
Albuquerque, NM 87125

Appeals:
Medicaid providers must submit requests for appeal within 90 days of the date of this notice. Appeals and requests for reconsideration of a denial determination must be submitted in writing to the address identified below and include at a minimum: a summary of the appeal or reconsideration request, the member’s name, member’s identification number, date of service(s), reason(s) why the denial should be reversed and copies of related documentation and /or applicable medical records to support appropriateness of the service rendered.

Appeals of behavioral health denials, appeals for requests for reconsideration for medical necessity or authorizations issues, and all other claim inquiries should be sent to:

Presbyterian Health Plan
Attn: Appeals Coordinator
P.O. Box 27489
Albuquerque, NM 87199-7489

Presbyterian Health Plan Commercial

Customer Service Number: 1-505-923-5678 or 1-800-356-2219 TDD 1-877-298-7407

Claims Address:
Presbyterian Health Plan
P.O. Box 2216
Maryland Heights, MO 63043

Appeals:
As the provider acting on behalf of the member and with his/her consent, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this document. You may file an appeal by writing to:

Presbyterian Health Plan
(ATTN: Appeals Coordinator)
P.O. Box 27489
Albuquerque, NM 87125-7489
1-505-923-5678 or toll - free 1-800-356-2219

Presbyterian Health Plan Medicare

Customer Service Number: 1-505-923-5678 or 1-800-356-2219 TDD 1-877-298-7407

Claims Address:
Presbyterian Health Plan
P.O. Box 2216
Maryland Heights, MO 63043

Appeals:
Contracted providers participating in provider network(s) for Medicare Advantage plans may request an appeal of a denial determination. Appeals must be submitted within 60 days of the date of this notice. You may file an appeal by writing to:

Presbyterian Health Plan
(ATTN: Appeals Coordinator)
P.O. Box 27489
Albuquerque, NM 87125-7489
1-505-923-5678 or toll - free 1-800-356-2219

Non-contracted providers, pursuant to the Centers for Medicare and Medicaid Services (CMS) regulations governing the Medicare Advantage program, may request a reconsideration of a Medicare Advantage plan denial of payment. Requests for reconsideration of a denied claim must be submitted within 60 days of the date of this remittance advice and a signed waiver of liability (WOL) statement is required by CMS. The form can be found at:

www.magellanprovider.com/waiverofliability

The request for reconsideration of a denied claim must be submitted in writing and should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider’s disagreement about reimbursement. You may file an appeal (request for reconsideration) in writing to:

Presbyterian Health Plan
(ATTN: Appeals Coordinator)
P.O. Box 27489
Albuquerque, NM 87125-7489
1-505-923-5678 or toll - free 1-800-356-2219

If your patient is a Medicaid / Qualified Medicare Beneficiary, review your records for any wrongfully collected deductible, coinsurance or copayment. This amount may be billed to a subsequent payor.

Sharp Health Plan Commercial

Customer Service Number: 866-512-6190

Claims Address:
Human Affairs International of CA, Inc
Sharp Health Plan
P.O. Box 710430
San Diego, CA 92171

Appeals:
Member appeal rights are described separately on the back of the Member's Explanation of Benefits.

Special Rule for Providers of California Members of SHARP MHSA plans:

Acting on your own behalf, you have the right to appeal or request reconsideration of a claim, to seek resolution of a billing determination, to contest a request for reimbursement of an overpayment of a claim, or to address any other contract dispute within 365 days of the date of this statement.

For information on filing a provider dispute (including an appeal), log on to www.magellanhealth.com/provider or www.magellanprovider.com Click "News & Publications", then "Handbooks", then "State-, Plan-, and EAP-specific Supplements", then "California", and then “Appendices - Claims Settlement Practices and Dispute Resolution”.

If you suspect Fraud or Abuse involving health benefits, please call the toll-free California Fraud Hotline at 1-800-424-6074.

Human Affairs International of CA
P O Box 710430
San Diego, CA 92171

Sharp Health Plan Medicare

St Vincent USFHP

Customer Service Number: 1-800-971-2273 TTY 1-800-635-2883

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 1099
Maryland Heights, MO 63043

Appeals:
In-Network Providers Only: As the provider acting on his/her/its own behalf, you have the right to request a provider claim dispute within 60 calendar days of receipt of this explanation of payment. Out-of-Network Providers Only: As the provider acting on behalf of the member and specifically appointed by the member as his or her representative, you have the right to request a review of any adverse determination regarding coverage under this plan within 90 days of receipt of this explanation of payment.

Send your request to:

Magellan Healthcare
Attn: Appeals
P.O. Box 2128
Maryland Heights, MO 63043
Fax: 1-888-656-3820 Phone: 1-800-201-3957

Yale Health Plan

Customer Service Number: 800-327-9240 / TDD 800-456-4006

Claims Address:
Magellan Behavioral Health Systems, LLC.
P.O. Box 1568
Maryland Heights, MO 63043

Appeals:
As the provider acting on his/her/its own behalf, you have the right to request a provider claim dispute within 60 calendar days of receipt of this explanation of payment.

Out-of-Network Providers Only:
As the provider acting on behalf of the member and specifically appointed by the member as his or her representative, you have the right to request a review of any adverse determination regarding coverage under this plan within 180 days of receipt of this explanation of payment.

Send your request to:

Magellan Appeals
P.O. Box 2128
Maryland Heights, MO 63043