Provider Appeals
Provider Billing Dispute and
Medical Necessity Procedure
Determination Appeal Process
The Adverse Determination Appeal Process applies when a provider is at financial risk for the cost of a claim. Appeals for hospital claims follow the process outlined in the hospital’s current agreement with Regence.
There are two types of claim denials that are included
in the Adverse Determination Appeal Process:
- Billing disputes or coding edits, or
- Medical necessity.
Examples of both types are listed below:
Billing disputes or coding edit denials:
- A claim that includes a new patient office or other
outpatient visit is submitted for an existing patient
and is denied.
- A claim for the professional component of a single
view, frontal chest X-ray is denied as included in
another paid service (bundled).
Medical necessity denial:
- A claim and supporting medical documentation for
a corneal ring implant is denied as not medically
necessary.
The following are NOT considered Adverse Determination
Appeals:
- You believe Regence should have reimbursed at a
higher percentage of billed charges. Please contact
Customer Service for assistance.
- You submit a revised claim with updated information
for a claim Regence has already adjudicated. Please
use a Corrected
Claim Form (PDF).
- You believe Regence applied the incorrect Diagnosis-Related
Group (DRG) to a hospital claim. This is a pricing
question. Please contact Customer Service for assistance.
- You are inquiring about a claim processing issue
(e.g., denial, payment or timely filing). Please
contact Customer Service for
assistance.
Learn more about our Adverse
Determination Appeal Process.
Use the Appeal
Form for Provider Billing Dispute and Medical Necessity
Denial (PDF) to
submit an Adverse Determination Appeal for a claim
payment decision.
Do not use this form to submit a corrected
claim or a member appeal.
The Regence Member
Appeal Process applies when
a member is or may be at financial risk for the cost
of the claim.
Voluntary binding external review
A voluntary binding external review option is available for physicians and other health care professionals who have exhausted our internal provider appeal process for billing disputes and are dissatisfied with the results. This external review is available through MES Solutions.
MES Solutions charges providers an up-front fee ranging from $50 to approximately $250, depending on the amount in dispute. If the Regence determination is overturned by MES Solutions, Regence is required to reimburse providers for this fee. External review is voluntary and by choosing this option providers agree that the external review decision is binding for both parties.
In order to be eligible for external review, the amount in dispute must exceed $500. Providers may, however, submit disputes for lesser amounts if they expect to reach the $500 level within one year. MES Solutions will monitor the amounts and notify providers when they reach the $500 level.
Audit Appeal Process
The Audit Appeal Process is intended to give providers an opportunity to request reconsideration
of audit findings issued by Regence and to ensure we have reviewed all information
relevant to the audit findings.
Learn more about our Audit
Appeal Process.
Provider Contract Termination Appeals
A contracted provider may initiate an appeal of a contract termination decision made by
Regence through the Provider Contract Termination Appeal Process.
Learn more about our Provider Contract Termination Appeal Process.
Reconsideration requests for Medical and Reimbursement
policies
Requests for review of a policy determination not related to
a claim may be submitted using the:
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