![]() Do not attach double-sided documents to the inquiry.Ĭlaims submitted with a "Delay Reason Code 7 or 9" and an "Attachment Type EB" will pend for manual review and will be noted with new Explanation of Benefits Code:ĮOB 05102 - MANUAL REVIEW OF ATTACHED DOCUMENTATION FOR TIMELY FILING Since these documents are scanned, attach only single-sided documents to the inquiry. Note: Each submission requires a DRC code, the EB Attachment Type, and copies of documentation (explanation of benefits, vouchers and attachments). Mail the printed cover sheet and corresponding documentation to the PO Box address noted on the cover sheet. If you are unable to electronically upload the documentation, print out the cover sheet that will be used to connect your documentation to your request. Upload the proof of timely filing documentation. The Attachment Type 'EB' must be used to identify the attachment as an explanation of benefits or a remittance advice.ĥ. The Explanation of Benefits/Remittance Advice must be attached to the claim.Ĥ. Original claims rejected or denied due to a reason unrelated to the billing limitation rules (#9)ģ. ![]() Include the "Delay Reason Code (DRC)" in the "Additional Claims Information" section. Enter the claim electronically through the NCTracks Provider Portal.Ģ. You must include this signed statement with your grievance.To provide the required documentation for a time limit override through the NCTracks Provider Portal, follow these steps:ġ.(Note: You may appoint a physician or a Provider.) For example: “I appoint to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services.” Provide your Medicare Advantage health plan with your name, your Medicare number and a statement which appoints an individual as your representative.You may appoint an individual to act as your representative to file the grievance for you by following the steps below: Someone else may file the grievance for you on your behalf.For Part B drugs, your Medicare Advantage plan will provide a decision as fast as possible, but no later than 24 hours in Time-Sensitive situations with no allowable extensions.Ī grievance may be filed by any of the following: If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as fast as possible, but no later than seventy-two (72) hours-plus 14 calendar days, if an extension is taken-after receiving the request. your ability to regain maximum function.A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize: You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. Complaints and appeals may be filed over the phone or in writing. ![]() There is also a complaint process if you are not satisfied with the quality of services that you received from United Behavioral Health or your behavioral health practitioner. United Behavioral Health offers an appeal process if you are not satisfied with a care advocacy or claims payment decision related to behavioral health services. You must include this signed statement with your appeal.Your representative must also sign and date this statement.Provide your Medicare Beneficiary Indentifier (MBI) from your member ID card.Provide your name, address and phone number and that of your representative, if applicable.(Note: You may appoint a physician or a Provider.) For example: “I appoint to act as my representative in requesting an appeal from your Medicare Advantage health plan regarding the denial or discontinuation of medical services.” ![]() Fill out the Appointment of Representative Form (PDF) and mail it to your Medicare Advantage plan or.You may appoint an individual to act as your representative to file the appeal for you by following the steps below: Someone else may file the appeal for you on your behalf.An appeal may be filed by any of the following:
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