Did Your Claim Fail to Process as Expected? Here Are Your Next Steps

Fecha: 21/06/23

A Message for Ambetter Providers. Please share with your Billing Team.

What to do if a claim did not process as expected and all details of the claim are correct.

Below are the steps you should take when a claim does not process as expected.  

• Claim Reconsideration (Level I Dispute) – A claim reconsideration must be submitted within 180 calendar days from the date of the original Explanation of Payment (EOP) or denial. Submit a reconsideration by:
  • Submitting a reconsideration request through the Secure Provider Portal
  • Calling Provider Services at 1-844-518-9505.
  • Mailing a Reconsideration and Claim Dispute Form to the address listed on the form.
• Claim Appeal (Level II Dispute) – An appeal must be submitted within 180 calendar days from the most recent EOP. Submit an appeal by:
  • Mailing a Reconsideration and Claim Dispute Form to the address listed on the form.

Your Provider Relations Representatives cannot submit these requests on your behalf.

Full details on the claims reconsideration and appeal processes can be found in the Ambetter Provider Manual.

If you have questions about this bulletin or other provider resources, please contact Provider Relations via the Contact Us Form or call Provider Services at 1-844-518-9505 (TTY 711).