Claims Denial – Reconsideration

What is a Claims Denial?

A claim is denied when a request for payment is received and processed by Vaya Health, but the request does not meet all the requirement criteria for payment approval.

Notification of Claim Denials are transmitted by the Remittance Advice (RA), or by other final notification of payment, payment denial, disallowance, payment adjustment, or notice of program or institutional reimbursement. You must submit all requests for reconsideration of Claim Denials within 30 days of this notification (usually by the RA.)

 

Submitting a Reconsideration Request

For claim reconsideration, the submitted form must include all claim(s) specifics, including but not limited to: the consumer’s name, member record number, date of service, service code, claim header information and all other relevant information regarding the claim.

If a signed and complete Level 1 form is not received within the required 30-day claim reconsideration period, then Vaya Health’s action to deny the claim is final without further written notification.

Claims Denial Reconsideration Request Form (Level 1) 

Level 1 Claim Denials are reviewed through a Desk Review process. Vaya Health will schedule a Level 1 Desk Review panel meeting within 60 days (not including paid holidays) from the receipt of the signed, complete and timely Level 1 form—unless there are documented extenuating circumstances for you or Vaya Health.

Following the Desk Review, a decision will be made to uphold, overturn, adjust, or determine that more information is needed about the claim. The panel will issue this written decision within 60 days of the date of the Level 1 Desk Review. The panel may request additional time to issue the decision if necessary, or may request a Level 2 meeting in order to receive more information about the claim.

 

What if I disagree with the Level 1 decision?

If you are dissatisfied with the Level 1 reconsideration decision, you can submit a written request for a Level 2 reconsideration review. The form to request Level 2 reconsideration will be attached to the Level 1 reconsideration decision. You must submit a signed and complete Level 2 form within 30 days of the Level 1 decision date. In the Level 2 form, you must specify whether you will participate in the Level 2 reconsideration in person, via telephone, or by submitting additional documentation. If a signed and complete Level 2 form is not received within the required 30-day period, Vaya Health’s decision is final without further written notification—unless the panel previously determined more information was needed during the Level 1 Desk Review.

Call 1-800-849-6127 toll free 24/7 to access mental health, substance use and intellectual and/or developmental disability services. Members can request materials in Spanish or English.

Llamar al número gratuito 1-800-849-6127 24/7 para obtener servicios y apoyo a la salud mental, discapacidades de desarrollo y abuso de sustancias. Los miembros pueden solicitar materiales en español o Inglés.