See also Prescription Drugs.Ĭlaims involving concurrent care decisions To qualify for expedited review, the request must be based upon exigent circumstances. For expedited requests, Providence Health Plan will notify your provider or you of its decision within 24 hours after receipt of the request. If you fail to obtain a Prior Authorization when it is required, any claims for the services that require Prior Authorization may be denied.įor standard requests, Providence Health Plan will notify your provider or you of its decision within 72 hours after receipt of the request. Providence will complete its review and notify your Provider or you of its decision by the earlier of (a) 48 hours after the additional information is received or, (b) if no additional information is provided, 48 hours after the additional information was due. Your Provider or you will then have 48 hours to submit the additional information. If Providence needs additional information to complete its review, it will notify your Provider or you within 24 hours after the request is received. Providence will notify your Provider or you of its decision within 72 hours after the Prior Authorization request is received. Prior authorization for services that involve urgent medical conditions If the information is not received within 15 days, the request will be denied. After receiving the additional information, Providence will complete its review and notify you and your Provider or just you of its decision within two business days. If Providence needs additional information to process the request, we will notify you and your Provider within two business days of receipt, and you or your provider will have 15 days to submit the additional information. Providence will let your Provider or you know if the Prior Authorization request is granted within two business days after it is received. Prior authorization of claims for medical conditions not considered urgent Once we receive the additional information, we will complete processing the Claim within 30 days. If we need additional information to complete the processing of your Claim, the notice of delay will state the additional information needed, and you (or your provider) will have 45 days to submit the additional information. We will notify you again within 45 days if additional time is needed. If we need additional time to process your Claim, we will explain the reason in a notice of delay that we will send you within 30 days after receiving your Claim. If Providence denies your claim, the EOB will contain an explanation of the denial. We will send an Explanation of Benefits (or EOB, see below) to you that will explain how your Claim was processed. Alternatively, you may send the information by fax to 50.Ĭlean claims will be processed within 30 days of receipt of your Claim.Mail your claim and supporting document(s) to the address below:.Attach a copy of receipt, provider invoice that includes the provider tax ID number, CPT codes, dates of service, ICD-10 codes (diagnosis codes), billed and paid amount with your proof of payment.Payment will be made to the Policyholder or, if deceased, to the Policyholder’s estate, unless payment to other parties is authorized in writing. See your Contract for details and exceptions. If your Provider bills you directly, and you pay for Services covered by your plan, we will reimburse you if you send us your claims information in writing. Payments for most Services are made directly to Providers. Usually, Providers file claims with us on your behalf. A claim is a request to an insurance company for payment of health care services.
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