Claim Dispute and Appeal Filing Guidelines

Date: 02/26/18

Managed Health Services (MHS) would like to remind providers of the informal claim dispute and appeal filing guidelines.

If the provider believes an improper payment of a claim for covered Medicaid services has occurred through either the omission of information, submission of incorrect claims data or a claims system error, the provider may file an informal claim dispute or objection by either:

• Submitting a copy of the MHS EOP along with a completed informal/dispute objection form,

OR

•  Submitting a written request for an informal dispute/objection resolution on company letterhead.

Informal claim disputes must be submitted in writing within 67 calendar days from the date on the EOP. The provider must include sufficient information for MHS to identify the claim(s) in question and the reason the provider is disputing to MHS’ processing of the claims(s).  Informal claims disputes must be sent to the following address:

Medical Claims:     Managed Health Services (MHS), P.O. Box 3000, Farmington, MO 63640

Behavioral Health Claims:  Behavioral Health Services, P.O. Box 6000, Farmington, MO 63640

In the event the provider is not satisfied with the informal claim dispute, the provider may file an administrative claim appeal. The informal dispute will come on the Explanation of Payment with EX code ZW or 0E. The appeal must be filed within 67 calendar days from receipt of the informal dispute notice or 90 calendar days from the date the informal claim dispute was submitted if MHS does not send a notice of informal dispute. An administrative appeal is not available to a provider who does not first submit an informal claim dispute.

This applies to providers and practitioners who are providing medical or behavioral health services. Appeal rights for claim issues are not preserved for providers merely by notifying your network representative or the call center.