Submit a Provider Administrative Claims Appeal
If you don't agree with how a claim was processed, you can request a provider administrative claim appeal using the Request for Claim Review Form. Forms must be submitted with all required information, including but not limited to completion of all fields denoted with an asterisk (*) and the correct Review Type box. If using “Other” on the form, you must document specific information pertaining to your request. Incomplete forms will be returned to the submitting provider for completion and appeal resubmission. Submit the form, the required written narrative and supporting documentation within your contracted timely filing limit to the address below. We have a one-level internal appeals process and will make a determination within 30 days following receipt of the appeal accompanied by the appropriate documentation. A resolution letter describing the decision is mailed to you upon completion of our review.
Please access the Provider Administrative Claims Appeal Process policy found on our website for additional information regarding this process.
The following types of provider administrative claim appeals are IN SCOPE for this process:
- Level of Compensation/Reimbursement
- Timely Filing of Claims
- Retroactive Eligibility
- Lack of Prior Authorization/Inpatient Notification Denials
- Non-Covered and/or Unlisted Code Denials
- Other Party Liability (OPL)/Third Party Liability (TPL)/Coordination of Benefits (COB)
- Provider Audit and Special Investigation Unit (SIU) Appeals
- Duplicate Claim Appeals
The following are considered Claim Issues and are OUT-OF-SCOPE for this process and must be sent to the appropriate departments:
- Claim Adjustments
- Corrected Claims
- Claim Resubmissions
- Claims Involving OPL/TPL/COB*
*Note: Claims issues involving OPL/TPL/COB are not necessarily appeals involving OPL/TPL/COB claims. Providers are responsible for sending their requests to the appropriate address via the required method(s).
Mail appeals and supporting documents to:Well Sense Health Plan
Attn: Provider Appeals
PO Box 55049
Boston, MA 02205-5049
For more detailed information on appeals, please see section 10 of the Provider Manual.