Provider Appeals

Provider Billing Dispute and Medical Necessity Procedure
Determination Appeal Process
The Adverse Determination Appeal Process applies when a provider is at financial risk for the cost of a claim. Appeals for hospital claims follow the process outlined in the hospital’s current agreement with Regence.

There are two types of claim denials that are included in the Adverse Determination Appeal Process:

1. Billing disputes or coding edits, or
2. Medical necessity.

Examples of both types are listed below:

Billing disputes or coding edit denials:

• A claim that includes a new patient office or other outpatient visit is submitted for an existing patient and is denied.
• A claim for the professional component of a single view, frontal chest X-ray is denied as included in another paid service (bundled).

Medical necessity denial:

• A claim and supporting medical documentation for a corneal ring implant is denied as not medically necessary.

The following are NOT considered Adverse Determination Appeals:

• You believe Regence should have reimbursed at a higher percentage of billed charges. Please contact Customer Service for assistance.
• You submit a revised claim with updated information for a claim Regence has already adjudicated. Please use a Corrected Claim Coversheet (PDF).
• You believe Regence applied the incorrect Diagnosis-Related Group (DRG) to a hospital claim. This is a pricing question. Please contact Customer Service for assistance.
• You are inquiring about a claim processing issue (e.g., denial, payment or timely filing). Please contact Customer Service for assistance.

Learn more about our Adverse Determination Appeal Process.

Use the Appeal Form for Provider Billing Dispute and Medical Necessity Denial (PDF) form to submit an Adverse Determination Appeal for a claim payment decision.

Do not use this form to submit a corrected claim or a member appeal.

The Regence Member Appeal Process applies when a member is or may be at financial risk for the cost of the claim.

Voluntary binding external review
A voluntary binding external review option is available for physicians and other health care professionals who have exhausted our internal provider appeal process for billing disputes and are dissatisfied with the results. This external review is available through MES Solutions.

MES Solutions charges providers an up-front fee ranging from $50 to approximately $250, depending on the amount in dispute. If the Regence determination is overturned by MES Solutions, Regence is required to reimburse providers for this fee. External review is voluntary and by choosing this option providers agree that the external review decision is binding for both parties.

In order to be eligible for external review, the amount in dispute must exceed $500. Providers may, however, submit disputes for lesser amounts if they expect to reach the $500 level within one year. MES Solutions will monitor the amounts and notify providers when they reach the $500 level.

Audit Appeal Process
The Audit Appeal Process is intended to give providers an opportunity to request reconsideration of audit findings issued by Regence and to ensure we have reviewed all information relevant to the audit findings.

Learn more about our Audit Appeal Process.

Provider Contract Termination Appeals
A contracted provider may initiate an appeal of a contract termination decision made by Regence through the Provider Contract Termination Appeal Process.

Learn more about our Provider Contract Termination Appeal Process.

Reconsideration requests for Medical and Reimbursement policies
Requests for review of a policy determination not related to a claim may be submitted using the:

• Medical Policy Review Request process, or the
• Reimbursement Policy Request for Review process