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NJ Appeals – Dentists – United Concordia Dental Insurance

Filing an Appeal in NJ

 

If a provider disagrees with United Concordia’s payment of claims decision, the decision may be appealed. United Concordia provides full opportunity for providers to appeal payment decisions. This means a provider can request an appeal following the steps described below.

 

Internal appeals system

If you disagree with the result of United Concordia’s claim processing determination, you may request a review by United Concordia.

 

Arbitration system

If you disagree with the result of United Concordia’s internal appeal determination, you may request that the matter be referred to arbitration.

 

What can and cannot be appealed?

To appeal a claim, there must be a disputed amount.

This means that there must be a charge or portion of a charge that United Concordia has decided is not payable. The amount in dispute is calculated as the amount of money United Concordia would pay if the services involved had been determined to be payable.

Some examples of the type of claims that cannot be appealed:

  • The claim is denied based on a Utilization Review determination, a determination of member ineligibility, coordination of benefits, or fraud investigation
  • The amount United Concordia determines to be the allowable charge
  • Denial of service(s) as exceeding the patient’s contract year maximum or orthodontic lifetime maximum

 

How do I request an internal appeal?

If you disagree with our claims payment decision and want to file an appeal, you must do so within 180 calendar days. The Health Care Provider Application to Appeal a Claims Determination  must be completed and sent to:

United Concordia
PO Box 69420
Attn: Andrew LaCour
Harrisburg, PA 17106-9420

 

What happens during an internal review?

United Concordia’s Dental Specialists will review your request. They will review all documentation, including documentation submitted with your letter (i.e. narrative explanations, x-rays, clinical notes, photographs, etc.), and conduct a thorough investigation. They may contact you for additional information, and in some cases, refer the claim to a Dentist Advisor.

The review may result in whole or partial approval of the disputed costs, or confirmation of the initial decision. You will receive written notification within 30 calendar days of the review decision and the action taken. The member will receive a copy of the review decision regardless of who initiated the review request.

 

How do I request arbitration?

  • If you disagree with the result of United Concordia’s internal appeal determination, you may request that the matter be referred to arbitration.
  • To appeal a claim to arbitration, there must be a disputed amount of at least $1,000. A provider may aggregate disputed claim amounts to meet this minimum threshold.
  • MAXIMUS, Inc. is the current arbitration organization for New Jersey’s Program for Independent Claims Payment Arbitration.
  • The application can be accessed at https://njpicpa.maximus.com/.
  • MAXIMUS will review the dispute and issue a decision within 30 calendar days following receipt of the required documentation.

The arbitration is non-appealable and binding on all parties to the dispute.

 

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