Appeals and Disputes
MultiPlan understands the importance of streamlined and effective processes for resolving issues. Below is a summary of the most common types of disputes that providers may encounter during the course of participating in our networks.
Both you, as a participating provider, and our clients have the right to dispute claims repricing activity. When a problem arises, you should contact our Service Operations department as soon as possible, as required by your contract, to provide all information pertinent to the problem. You can request service online or call 800-950-7040. If the issue can't be resolved immediately, it will be escalated to a provider service representative who will conduct an inquiry, contacting the client and/or MultiPlan provider service representative as appropriate. Escalated issues are resolved in less than five business days on average.
Pre Payment Disputed Claims.
- If you discover that you sent an erroneous claim, you must notify the client within sixty (60) days of the date the claim was issued.
- If a client receives a claim that is not a "clean claim" (that is, containing all complete and accurate information required for adjudication) or if the client required further information to process the claim or has some other dispute to be addressed prior to adjudication, they will provide you with written notification within thirty (30) business days of receipt of the claim and prior to payment of the claim. Please provide complete and accurate information requested within thirty (30) business days of the client's request. They will adjudicate the claim within thirty (30) business days of receipt of the additional and/or corrected information.
Post Payment Disputed Claims. Unless otherwise required by law, you or the client may challenge payments made to you during the twelve (12) months following your receipt of payment from the client; otherwise such payment shall be deemed final.
Appealing Credentialing and Termination Decisions
As a participating provider, you have the right to appeal credentialing or termination decisions made by MultiPlan. MultiPlan complies with all state and federal mandates with respect to appeals for providers terminated or rejected from the PHCS Network and/or the MultiPlan Network. Terminated or rejected providers may submit a request for an appeal as outlined in the letter of rejection/termination sent by MultiPlan. This request for appeal must be received by MultiPlan within thirty (30) days of the date of the rejection/termination letter. Upon receipt of the letter by MultiPlan, the appeal is forwarded to the MultiPlan Appeals Committee for review.
The appeal review is based on any written information submitted by the provider, in conjunction with any information previously in MultiPlan's files. Unless required by state or federal law, MultiPlan does not meet in person or by telephone with the provider, or representative. If the Appeals Committee reverses a termination decision, the provider's participating status is reinstated as of the date of the initial adverse decision, unless otherwise determined by the Appeals Committee.
Additional information regarding the appeals process can be found in the Participating Professional Handbook.