Claims, Appeals, and Grievances

Claims Payment Dispute

A claims payment dispute is a request from a health care provider for a post service review of claims that have been denied or underpaid.  A claims payment dispute is not a pre-service appeal or a claim/administrative appeal. MedStar Family Choice created a Claims Payment Dispute Form. Providers must complete the form in its entirety and submit all necessary documentation.

Click here for more information regarding claims payment disputes.

Appeals

MedStar Family Choice recognizes the right of a member (enrollee) and/or authorized representative or providers (i.e. clinician or facility) to request an Appeal of an Adverse Action (denial) that results in member financial liability or denied service. MedStar Family Choice reviews all appeal requests of Adverse Actions and resolves appeals in a timely, appropriate manner. MedStar Family Choice provides notice of the appeals process in a culturally and linguistically appropriate manner. Methods of informing members and providers about this process include articles in the newsletters, and sections in the member handbook and provider manual. 

Click here for more information and resources regarding appeals.

Grievances

MedStar Family Choice maintains a process for recording and triaging Grievances and Appeals of Grievance resolutions so that they may be resolved in a manner that is consistent with MedStar Family Choice service standards, that is responsive to the needs of members and providers, that meets or exceeds State and regulatory standards and that permits tracking and reporting. Contact Member Services at 888-404-3549 for more information.