Appeal Rights

Contracted Provider: In accordance with the Medicare Managed Care guidance, contracted providers do not have an appeal right. Community Health Plan of Washington (CHPW) has a review process to address contracted provider claim issues. Requests for contracted provider claim reviews should be received by CHPW within 120 days from the date of the Provider Remittance Advice (PRA). A copy of the PRA and supporting documentation (i.e., medical records) must be submitted with the request.

Non-Contracted Provider: In accordance with the Medicare Managed Care guidance, non-contracted providers have appeal rights. Appeal rights apply to any claim CHPW has denied payment. Requests for payment appeals must include a completed and signed “Waiver of Liability” (WOL) statement. CHPW cannot begin the appeals process without a signed WOL. Requests for appeals that do not include a WOL will be dismissed. Requests for payment appeals must be filed within 60 calendar days of receiving the PRA. A copy of this PRA and supporting documentation must be submitted with the appeal request. CHPW must make a decision regarding the appeal within 60 calendar days from the date the appeal request is received.
 
If CHPW upholds the initial payment denial following review of the appeal or does not make a decision within 60 calendar days from the date the appeal request was received, CHPW will submit the appeal request to the IRE for review. The IRE will review the appeal and notify the provider in writing of the decision. If CHPW upholds the original claim denial, non-contracted providers have the right for the appeal to be reviewed by the CMS contracted IRE.

Payment Dispute Rights

Contracted Providers: Refer to Contracted Provider Appeal

Non-Contracted Providers: In accordance with Medicare Managed Care guidance, non-contracted providers have payment dispute rights. Payment dispute rights apply to any claim the provider contends the amount paid for a covered service is less than the amount that would have been paid by Original Medicare. Payment dispute rights apply to any claim there is a disagreement between the non-contracted provider and CHPW regarding the decision to pay for a different service than the billed service. Requests for payment disputes must be filed within 120 calendar days of the PRA. CHPW must make a decision regarding the payment dispute within 30 calendar days from the date the payment dispute is received.

Payment disputes are subject to CMS review as CHPW is required to pay non-contracted providers the same amount the provider would have received had the provider billed Original Medicare. The non-contracted provider payment dispute process cannot be used to challenge payment denials that result in zero payment. Payment denials may be appealed as described in the Non-Contracted Provider Appeal section above.

Question about the non-contracted provider appeal or payment dispute process, can be directed to our Customer Service department toll free at 1-800-942-0247 (TTY 711), 7 days a week, from 8 a.m. to 8 p.m.

Please submit your Review and or Payment Dispute to:

Community Health Plan of Washington
Attn: Community HealthFirst Appeals & Grievances
1111 Third Avenue, Suite 400
Seattle, WA 98101