Appeals & Grievances
CareFirst Community Health Plan Maryland (CareFirst CHPMD) Provider Complaint Process
CareFirst CHPMD wants to have a positive working relationship with all of our health care providers. We recognize that we may not always be able to achieve this goal and want to hear from our providers when they are dissatisfied with an administrative process within CareFirst CHPMD. A CareFirst CHPMD provider may file a grievance at any time in writing or by calling any CareFirst CHPMD staff member.
Grievances are managed by the CareFirst CHPMD Appeals and Grievances (A&G) Department. Grievances are accepted verbally or in writing by any CareFirst CHPMD staff person and then routed to the A&G Department. All grievances are responded to in writing; acknowledged within 5 business days of receipt; investigated by the department that is the subject of the grievance, and resolved within 30 calendar days of receipt. All provider grievances are logged, categorized and on completion, are evaluated by the Appeals and Grievances Committee and the Quality Improvement Committee for patterns and/or trends.
If a provider is not satisfied with the actions taken by CareFirst CHPMD in addressing the grievance, they may contact the State’s Complaint Resolution Unit at 1-800- 284-4510 for further action.
CareFirst Community Health Plan Maryland (CareFirst CHPMD) Provider Appeal Process
A provider may appeal a decision by CareFirst CHPMD to deny or partially deny payment of services rendered. An appeal must be filed within 90 days of the date of the denial of payment.
CareFirst CHPMD will acknowledge an appeal in writing within 5 business days of receipt. CareFirst CHPMD will resolve an appeal in writing within 30 days of receipt.
CareFirst CHPMD will provide a reasonable opportunity to present evidence and allegations of fact or law, in person as well as in writing. CareFirst CHPMD will permit the provider the opportunity before and during the appeal process to examine the appeals case file including medical records and any other documents and records. When reviewing the appeal, CareFirst CHPMD will consider a full investigation of the substance of the appeal including any clinical aspects. CareFirst CHPMD will appoint a new reviewer, who was not involved with the initial determination, is not a subordinate of any person involved in the initial determination and is of the same or similar specialty as typically treats the medical condition or performs the procedure on appeals of an adverse determination.
Notification of the Outcome of Appeal
When the outcome of the appeal is known, the results and the date of the appeal resolution will be provided in writing to the provider. The resolution letter will contain the rationale for the determination, the credentials of the reviewer involved in the determination, and the opportunity for a second level appeal.
Second Level Appeal
At a second level review, Provider Claim Appeal disputes related to a denial based on medical necessity that remain unresolved subsequent to the Provider Appeal is reviewed by a physician contracted by CareFirst CHPMD who is not a Network Provider. The contracted physician resolving the Claim Payment Appeal dispute holds the same specialty or a related specialty as the Appealing Provider. The contracted physician’s determination is binding by CareFirst CHPMD and the Appealing Provider.
The provider must notify CareFirst CHPMD of their request for a second level appeal within 15 business days of the date of the letter noting the outcome of the appeal. CareFirst CHPMD will acknowledge the request for a second level appeal in writing within 5 days of receipt. A meeting between the Chief Executive Officer CareFirst Community Health Plan Maryland or designee, the provider and a provider who was not involved in the case is scheduled. CareFirst CHPMD appoints a new reviewer who was not involved with the initial determination, is not a subordinate of any person involved in the initial appeal determination and is of the same or similar specialty as typically treats the medical condition or performs the procedure. The selected reviewer receives all documentation used in the initial appeal process for review and any additional information provided for the second level of review. During the informal meeting the appellant, the reviewer and the Chief Executive Officer, or his/her designee, review the evidence and a determination is made by the reviewer. The appellant is notified in writing of the decision. This is the final level of appeal with CareFirst CHPMD.
CareFirst CHPMD will pay a claim within 30 days of the appeal decision when a claim denial is overturned.
CareFirst CHPMD will not take punitive action against a provider for utilizing the provider appeal process.