• Provider Payment Dispute: The claim has been finalized but you disagree with the amount that you were paid;
• Provider Administrative Plea/Appeal: The claim has been finalized, but you disagree with the administrative denial that has been applied. An administrative denial is applied within the claims process when it is determined that the provider failed to follow the terms and conditions of their contract. Examples of administrative denials are as follows: denials such as no prior authorization or late notification.

Please be aware, there are two common claim-related issues that are not considered claim payment disputes. To avoid confusion with claim payment disputes, these are briefly defined below. They are:

• Claim Inquiry: A question about a claim, but not a request to change a claim payment.
• Claims Correspondence: When IntegraNet requests further information to finalize a claim.

Typically, these requests include medical records, itemized bills, or information about other insurance a member may have. A full list of correspondence related materials is in the correspondence section of this provider manual.

Claims that were denied for lack of medical necessity should follow the existing provider post-service appeal process. An example of a post-service medical necessity appeal scenario would be as follows:

• On clinical review, the services related to the prior authorization request were deemed not medically necessary but services were rendered and claim payment was denied. For more information on each of these, please refer to the appropriate section in this provider manual.

The IntegraNet provider payment dispute process consists of two internal steps. You will not be penalized for filing a claim payment dispute and no action is required by the member.

• 1.Claim Payment Reconsideration: This is first step in the IntegraNet provider payment dispute process. The reconsideration represents your initial request for an investigation into the outcome of the claim. Most issues are resolved at the claim payment reconsideration step.
• 2.Claim Payment Appeal: The second step in the IntegraNet provider payment dispute process. If you disagree with the outcome of the reconsideration, you may request an additional review as a claim payment appeal.

A claim payment dispute may be submitted for multiple reason(s) including:

• Contractual payment issues
• Disagreements over reduced claims or zero-paid claims not related to medical necessity
• Post-service authorization issues
• Other health insurance denial issues
• Claim code editing issues
• Duplicate claim issues
• Retro-eligibility issues
• Experimental/investigational procedure issues
• Claim data issues
• Timely filing issues*

*Timely filing issues.

IntegraNet will consider reimbursement of a claim which has been denied due to failure to meet timely filing if you can: 1) provide documentation the claim was submitted within the timely filing requirements or 2) demonstrate good cause exists.