MedStar Family Choice will accept appeal requests in writing within applicable time frames.  Appeal requests must include a clearly expressed request for the appeal or re-evaluation. The request must include the reason and supporting documentation as to why the Adverse Action (denial) was believed to have been issued incorrectly.   

MedStar Family Choice will send a letter to confirm the appeal within 5 business days of receipt of the appeal request. A decision letter will be sent within 30 days from the date of the appeal..

Provider Appeals

Providers acting on their own behalf are defined as those who dispute Adverse Actions when the service has already been provided to the member and there is no member financial liability. First level appeals must be submitted in writing within 90 business days from the date of the explanation of benefits (EOB) / denial notice using the Medicaid Appeal Form. The appeal must outline reasons for the appeal with all necessary documentation including a copy of the claim and the EOB, when applicable. Appeal requests for medical necessity decisions must include supporting clinical/medical documentation.

A provider appeal must include a clearly expressed reason for re-evaluation, with an explanation  as to why the denial was believed to have been issued incorrectly. An acknowledgement of receipt of the appeal (first and second level) will occur within five business days of receipt.

Second level appeals must be submitted within 30 calendar days of the first level appeal notification letter. The second level appeal is the final level of appeal. MFC will respond within 30 calendar days of receipt of the second level appeal. Please use the Medicaid Appeal Form and mail the written request with all supporting documentation, such as clinical/medical documentation.

For questions, please call our Provider Customer Service Line at 800-261-3371, which is available Monday through Friday, 8:30 a.m. to 5:00 p.m.

Timely Filing Appeals

The following information was compiled to help clarify the documentation required as valid proof of timely filing documentation. When submitting an appeal request of a denial to substantiate timely filing, please include the following:

For paper claim submissions:

  • Submit documentation that the claim was received by MedStar Family Choice including but not limited to FedEx receipt, signature form from the USPS, etc.
  • Copy of Explanation of Benefits (EOB) from primary insurer that shows timely submission from the date the carrier processed the claim.

For electronic claim submissions:

  • Submit an electronic data interchange (EDI) acceptance report. Please note that confirmation of receipt from the provider’s clearing house would not be acceptable.
    • Note: A submission report alone is not considered proof of timely filing for EDI claims. It must be accompanied by an acceptance report.
  • The acceptance report must:
    • Include the actual wording that indicates the claims was either “accepted,” “received” and/or “acknowledged.
    • Show the claim was accepted, received, and/or acknowledged within the timely filing period.
  • Copy of the EOB from primary insurer that shows timely submission from the date the carrier processed the claim.

Member Appeals

Member appeals only have one level. A member (enrollee), representative (e.g. parent, guardian, friend, etc.), or provider (i.e. clinician or facility) acting on behalf of a member may request an appeal of an Adverse Action when the service has not yet been provided (pre-service), there is reduction of services, or  the service has already been provided and there is member financial liability.

Members must provide written consent for a provider or representative to appeal on their behalf via the Provider Permission Form for Member Appeals or any other format. The Appeal Review process begins at the time MedStar Family Choice receives the member’s consent.

All member appeals must be submitted in writing within 60 calendar days from the date of the denial notice. Send a written appeal request with all supporting documentation, such as clinical/medical documentation. Please include an explanation for the appeal (why the provider believes the claim was denied incorrectly) on the Medicaid Appeal Form.

If you have questions, please call us at 800-905-1722, option 3.

Use the mailing address below for all appeal requests below:

MedStar Family Choice
Appeals Processing
P.O. Box 43790
Baltimore, MD 21236

 

Information current as of: