When a claim is denied, providers have the right to request a formal administrative and clinical reconsideration. To ensure an efficient review by our clinical team, please follow this guide to compile and submit the necessary documentation.
Who Can Initiate an Appeal?
Appeals may be initiated by either the rendering provider or the member. Because clinical justification is required for medical necessity denials, provider-led submissions typically expedite the review process.
Required Documentation Checklist
To process an appeal, our clinical review team requires a complete documentation packet. Incomplete submissions will delay the determination. Please include the following four items:
- Original Claim Form: A copy of the initial CMS-1500 or UB-04 form submitted for the service or treatment.
- Explanation of Benefits (EOB) / Remittance Advice: A copy of the EOB or electronic remittance advice (ERA) reflecting the specific denial codes. This allows our team to accurately locate the transaction in our system.
- Supporting Clinical Documentation: The critical component of the packet. Submit all relevant charting, including physician notes, diagnostic test results, operative reports, or explicit clinical justifications establishing the medical necessity of the service.
- Provider Cover Letter: A brief narrative outlining the clinical rationale for reversing the determination, drawing attention to the specific medical records that substantiate the claim.
Submission Protocol via Email
To submit an appeal electronically, please follow this three-step protocol:
1.Compile the Packet:Verification.
Gather the original claim, EOB, comprehensive clinical records, and your cover letter. Ensure all documents are converted into clear, legible PDF files.
2.Transmit the Appeal:Dedicated Inbox.
Email the compiled PDF packet directly to the provider appeals queue at providers@betterhealthplan.com. (Note: Ensure this matches your provider-specific inbox if different from the member email).
3.Acknowledge Receipt:24–48 Business Hours.
Our team will log the appeal into our tracking system and issue an electronic confirmation of receipt within 24 to 48 business hours, initiating the formal review window.
Administrative Note: Missing documentation is the leading cause of appeal delays. If you require clarification on a specific denial code or need to verify the status of an ongoing appeal, please contact Provider Services directly via the secure provider portal or call the Provider Relations line listed on the member's insurance card.