Ambetter Health Member and Provider Appeals Processes

At Ambetter Health, both members and providers have the right to appeal decisions that affect their care and services. Understanding the differences and similarities between the member and provider appeal processes is crucial for ensuring transparency and fairness. This document provides a side-by-side comparison of the appeal processes for members and providers, highlighting the key steps, timelines and requirements involved. By familiarizing yourself with these processes, you can better navigate the system and advocate effectively for your needs or the needs of those you serve.

	Member Appeal	Provider Appeal
Appeal Definition	A request from a member or member representative related to a medical necessity decision to reduce, terminate, suspended or deny services.	A request from a provider related to a medical necessity decision or authorization-related issues for post-service claim denial.
Who can file?	Member or member representative. This includes providers with signed member consent.	The direct service provider or member’s primary care physician (PCP).
When does the appeal need to be filed?	180 days from the date of the Notice of Adverse Benefit Determination (NABD).	First-Level Appeal (Reconsideration): Must be received by the Health Plan within 90 days from the original Explanation of Payment (EOP). Second-Level Appeal (Dispute): Must be received by the Health Plan within 90 days from the original (First-Level/Reconsideration) Appeal Denial Notice. Note: Appeals made prior to the EOP will be closed as invalid. There will be no denial in our system to appeal.
Are there documents that must be included with the appeal?	None required. However, including all necessary records to support the appeal is suggested. Ambetter Health will make efforts to secure required medical records.	Yes. Include a Provider Request For Reconsideration And Claim Form. The request should also include medical records specific to the member’s health, to include but not limited to MD notes, lab/imaging results, specialty consults for “all” dates of service in question. To facilitate the clinical review and processing time of your request, please submit the medical records in chronological order for the applicable dates.
Are any forms required?	Signed consent is required when anyone other than the member is appealing.	Yes. Visit Ambetter Health Provider Resources to download the Provider Request For Reconsideration And Claim Dispute Form. Go to Claims and Claims Payment to find the Claim Dispute Form (PDF).
Where does the appeal get filed?	Member appeals can be filed orally or in writing. Mail: Ambetter Health ATTN: Appeals Department P.O. Box 459087 Fort Lauderdale, FL 33345-9087 Call:1-877-687-1169 (TTY 1-800-955-8770) Email: Sunshine_Appeals@centene.com Fax:1-866-534-5972	Mail First Request (Reconsideration) to: Ambetter Health Attn: Level I – Request for Reconsideration P.O. Box 5010 Farmington, MO 63640-5010 Mail Second Request (Dispute) to: Ambetter Health Attn: Level II – Claim Dispute P.O. Box 5010 Farmington, MO 63640-5010
How long does it take to review?	Standard pre-service appeal within 30 calendar days. Expedited pre-service appeal within 72 hours. Standard post-service appeal within 60 calendar days. External Review within 45 calendar days. Expedited External Review within 72 hours.	First-Level (Reconsideration) and Second-Level (Dispute) appeals will be reviewed within 60 days of receipt from the Health Plan. Note: Please allow up to 65 days for a response prior to escalating or submitting another request to allow for mail processing time. Sending in multiple requests without allowing appropriate processing time may cause additional delays.
Can the appeal be escalated?	Providers may request an “expedited plan appeal” on their patients’ behalf if they believe that waiting 30 days for a resolution would put their life, health or ability to attain, maintain or regain maximum function in danger. Expedited requests do not require a member’s written consent for the providers to appeal on the member’s behalf.	No. If a provider has a concern related to their Reconsideration/Claims Dispute request, they may reach out to their Provider Engagement Account Manager (PEAM). Providers can use the Find Your Account Manager tool to identify their designated PEAM.
Can services be continued during the appeal process?	Yes. The request must be made within 10 days after the NABD, or on or before the first day that services will be reduced, suspended or terminated. Providers may make this request if they are acting as the member’s representative. If services are continued, member may be liable for services if the final decision is not in their favor (upheld/denied).	N/A
What if I am not satisfied with initial appeal?	Member or member representative may file an External Review with the plan after exhausting our internal review process at any time up to 120 calendar days of the date of your appeal resolution letter. Plan will utilize an Independent Review Organization (IRO) to conduct an External Review.	Providers have two appeal levels for post service claims denials. First-Level Appeal (Reconsideration) and a Second-Level Appeal (Dispute). If following the Provider Claims Reconsideration (First-Level Appeal) and Dispute (Second-Level Appeal) process, the provider still does not agree with Ambetter Health’s final determination, the provider can utilize the Ambetter Health Provider Manual.