Alliance Health has a provider appeals system that is different from that offered to members that handles appeals promptly, consistently and fairly. The system is in compliance with state, federal, and NCDHHS requirements. Providers must exhaust the Alliance appeals process before seeking recourse under any other process permitted by contract or law. Alliance will not discriminate or retaliate against a provider for filing an appeal of an Alliance decision.
Provider notifications of Alliance decisions that are subject to appeal include a description of the provider’s right to appeal and the methods for submitting an appeal, the deadline for the appeal, and how to request an extension. Provider notifications will also include contact information for the Provider Complaint, Grievance and Appeal Coordinator for technical assistance.
Providers may submit an appeal through the provider web portal, certified US Mail, email, or in person at an Alliance office. The appeal will be accepted when it is accompanied by a completed Provider Request for Reconsideration form and is received within 30 calendar days of when the provider received the notification of the decision or when Alliance should have taken a required action and failed to do so. The Provider Request for Reconsideration form is posted on the Alliance web site and serves as a cover page to the provider appeal. Alliance will acknowledge receipt of appeals within 5 calendar days of the request. Appeals received after the 30 calendar day deadline will be denied. If a provider believes an appeal denied for timely filing was submitted within the appropriate time frame, the provider may submit documentation showing evidence of timely filing.
Providers may request an extension of the appeal deadline of up to 30 calendar days for good cause. A request for an extension must be submitted in writing using the Provider Request for Reconsideration Extension form by the provider web portal, certified US Mail, email or in person at the Alliance home office no later than 20 calendar days of when the provider received the notification of the decision. Extension requests are reviewed by Alliance to determine if good cause exists. Good cause includes, but is not limited to, voluminous nature of required evidence/supporting documentation, natural disasters, states of emergency, absence of crucial provider employee(s) and/or audits/investigations by other entities. Alliance will inform the provider of the decision to approve or deny the request to extend deadline within 3 calendar days of receipt.
Decisions that are not appealed by the provider by the aforementioned deadline or by the approved deadline extension are considered final by Alliance.
Network providers have the right to appeal certain actions taken by Alliance. The appeal process is available to network providers for the following reasons:
- Program integrity-related findings or activities
- Finding of waste or abuse by Alliance
- Finding of or recovery of an overpayment by Alliance
- Withhold or suspension of a payment related to waste or abuse concerns
- Termination of, or determination not to renew, an existing contract for LHD care/case management services
- Determination to de-certify and AMH+ or CMA (applicable to Medicaid providers only).
- Violation of terms between Alliance and provider
Out-of-network providers may appeal certain actions taken by Alliance. The appeal process is available to out-of-network providers for the following reasons:
- An out-of-network payment arrangement
- Finding of waste or abuse by Alliance
- Finding or recovery of an overpayment by Alliance
The appeals process is also available to providers based on enrollment denials for quality concerns. When a new enrollment application or renewal is denied, the denial notice sent to the requesting provider will include the denial, the reason and instructions for initiating the appeal process.
Provider appeals are reviewed by the Provider Appeals Committee consisting of at least 3 qualified individuals at senior management level with representation from Clinical, Business, and Network Operations that were not involved in the original decision, action or inaction that gave rise to the appeal. The provider appeals process includes a two-level review that includes a clinical peer reviewer for actions related to Provider conduct or competence that impact network status and/or Objective Quality Standards for State-funded services, and a one-level review for other actions. Clinical peer reviewers will have at least equal qualifications to the provider that requested the appeal.
Alliance will notify the provider in writing of the appeal outcome within 30 calendar days of receipt of a complete appeal request, or within 30 calendar days of receipt of all evidence when an extension has been granted. Previously approved and paid claims associated with overturned decisions will not be reversed for recovery. Appeal decisions regarding actions related to conduct or competence that impact network status and/or Objective Quality Standards for State-funded services will describe further appeal rights.
Appeals of an Alliance decision to suspend or withhold provider payment will be limited to whether Alliance had good cause to initiate the withhold or suspension of payment and will not address findings of fraud or abuse. The provider will be offered the opportunity to participate in person or by telephone when the provider has appealed whether Alliance had good cause to withhold or suspend payment to the provider. The appeal will be scheduled and a written decision will be issued within 15 business days of receipt of the appeal request.
