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Appeals and Inquiries

Three Levels of Review
Inquiries
Postservice Provider Appeals
External Review Options - M.D.s and D.O.s Only
Billing Dispute External Review Process

     Filing Fee

     Filing Fee

External Review Determinations Annual Report – Medical Necessity, Experimental, and Investigational Reviews 

Frequently Asked Questions 

Three Levels of Review

Learn about the three sequential levels of review for disputed claims:

Inquiries

If you are not satisfied with a claim adjudication, submit a provider inquiry and any accompanying information Wellmark should consider:

• Online – Submit an inquiry to Customer/Provider Service and track the progress of the inquiry online.
• By phone – Call the appropriate Customer/Provider Service phone number for Iowa or South Dakota.
• By fax or mail – Complete and submit the Iowa  (118KB) or South Dakota  (125KB) Provider Inquiry Form.

If the inquiry is not resolved to your satisfaction and new information is available, please submit a second inquiry with the additional information.

If no additional information is available, you may submit a postservice provider appeal.

Post-Service Provider Appeals

If you are not satisfied with Wellmark's determination after exhausting the process above, you may submit an appeal to Wellmark’s provider appeals department using the Iowa  (110KB) or South Dakota  (114KB) Provider Post-Service Appeal Form.

Please include any written comments, office notes, operative reports, or other relevant information for Wellmark to consider during the appeal. Wellmark will return incomplete forms to you.

You have 180 calendar days from the date of the remittance advice to dispute a claim adjudication action.

You may not initiate an appeal if:

• The plan member or plan member’s authorized representative has already filed a preservice appeal or a postservice review pertaining to the same service.
• The member has filed a lawsuit.

Wellmark will send you a letter dismissing the appeal if any of the above conditions exist. 

The appeal review will take into account all documents, medical records, or any additional information, regardless of whether the information was submitted or considered in the original determination or provider inquiry.

Appeals will be conducted by individuals not involved in the previous determination. Based on the type of issue being appealed, the following may conduct the review:

• Wellmark’s provider economics department
• Medical directors
• Medical review department
• Medical policy group
• Provider contracting departments
• Other business areas as needed
• A physician with the same or similar specialty or who has experience treating the same problems as those in question on the appeal (for medical necessity appeals)

Wellmark will notify you of the appeal decision within 30 calendar days of receipt of the appeal.

Note: The provider appeal process is available for postservice reviews only. Members may appeal preservice utilization review decisions in accordance with the member appeals process. If a provider would like to request a preservice appeal on behalf of the member, the provider will need to follow the member appeal process and be appointed by the member as an authorized representative using an Iowa  (41KB) or South Dakota  (37KB) Authorized Representative Appointment Form.

External Review Options - M.D.s and D.O.s Only

If you is not satisfied following a formal Appeal decision, the final step is an external review process. This step may be available when the claim in question is meets these general requirements:

• Services are provided to a Wellmark member by an Iowa or South Dakota physician (M.D.s and D.O.s only).
• Services are provided to a Wellmark Health Plan of Iowa member by an M.D. or D.O. in another state, when the physician contracts with Wellmark Health Plan of Iowa.

Claims for members covered by self-funded groups are not eligible for the external review process.

Depending on the claim in question, two distinct external review processes are available. Please review both explanations below before proceeding, then select the appropriate process to continue.

• Billing Dispute External Review Process – MES Solutions (MES) is the independent reviewer that resolves patient-specific billing disputes that concern the application of coding and payment rules and methodologies for covered fee-for-service claims, such as bundling, downcoding, application of a CPT^® modifier, or other reassignment of a code, payment when two or more CPT^® codes are billed together, or whether a payment enhancing modifier is appropriate.
• Medical Necessity, Experimental, or Investigational External Review Process – An external review process available for medical necessity, investigational, or experimental denials.

Billing Dispute External Review Process

If you are not satisfied after exhausting the postservice appeal process and the issue is for a billing dispute, you can begin the billing dispute process if the amount in dispute is greater than $500.*

MES Solutions (MES) is the independent reviewer that resolves patient-specific billing disputes, which concern the application of Wellmark’s coding and payment rules and methodologies for fee-for-service claims. This includes disputes regarding:

• bundling
• downcoding
• application of a CPT® modifier or other reassignment of a code
• payment when two or more CPT® codes are billed together or whether a payment enhancing modifier is appropriate

A separate process is available for Medical Necessity, Investigational, or Experimental reviews.

The billing dispute external review process is available to:

• Iowa and South Dakota M.D.s and D.O.s  providing services for a Wellmark member
• Out-of-state M.D.s and D.O.s who contract with Wellmark Health Plan of Iowa when the claim is for a Wellmark Health Plan of Iowa member

Claims for members covered by self-funded group health plans are not eligible for the external review process.

Qualifying physicians will receive a provider postservice appeal response letter noting that they may request a billing dispute external review.

To request an external review regarding a billing dispute, physicians must request the review within 90 days of the date of Wellmark’s postservice provider appeal decision.

* You may submit a billing dispute with an amount less than $500, if you notify MES Solutions (MES), the Billing Dispute Reviewer, that you intend to submit additional billing disputes during the one year following the submission of the original submission. The additional billing disputes you submit must involve the same issue as the original billing dispute. MES will defer consideration of the billing dispute with the physician until all similar billing disputes accumulate to the $500 amount. If you do not submit additional billing disputes within one year, or do not submit disputes that exceed $500 in total, MES will dismiss the original billing dispute and any additional, related billing disputes.

Submit requests for a billing dispute external review to MES:

• Online – via MES Solutions Billing Dispute Resolution Web . Submit the billing dispute review request and pay the accompanying filing fee online.
• By fax or mail – Download the Billing Dispute Resolution Referral Form from the MES Solutions Web site . Fill out and submit the form with appropriate supporting information, to MES:
  • MES Solutions
    Attn: BDRP Dept.
    100 Morse St.
    Norwood, MA 02062
    Fax: 1-888-868-2087

Filing Fee

You are required to submit a filing fee with billing dispute referrals.

• If the amount in dispute is less than $1,000, the filing fee is $50.
• If the amount in dispute is more than $1,000, the filling fee is $50 plus 5 % of the amount over $1,000, not to exceed 50 percent of the cost of the review.

Once MES obtains all information related to the billing dispute, MES will calculate the filing fee, which you can pay by:

1. MasterCard, Visa or Discover credit or debit cards on MES Solutions’ secure Bill Dispute Resolution Web site .
2. Check addressed to:
   MES Solutions
   Attn: BDRP Dept.
   100 Morse St.
   Norwood, MA 02062

MES must receive the filing fee before reviewing the billing dispute. If you are the prevailing party in the billing dispute, MES will refund the filing fee (learn more about filing fees on the MES Solutions Web site ).

Once MES receives the request and filing fee, MES will contact Wellmark and request appropriate documentation relating to the billing dispute. Wellmark has 30 days to provide the requested information to MES. MES will make a decision no later than 30 days after receiving the documentation necessary for the review, and will notify the physician/physician group and Wellmark.

If MES issues a decision that requires Wellmark to pay the physician/physician group, Wellmark will make the payment within 15 days of being notified about the decision.

Medical Necessity, Experimental, or Investigational External Review Process

If you are not satisfied after exhausting the postservice appeal process and the issue is for a medical necessity, experimental, or investigational review, you can begin the medical necessity, experimental, or investigational review process.

Medical Review Institute of America (MRIoA) is the independent reviewer that resolves patient-specific medical necessity, experimental, or investigational issues, which includes claims that are not covered because the services are considered:

• not medically necessary
• experimental or investigational

A separate process is available for billing disputes.

The medical necessity, experimental, or investigational external review process is available to:

• Iowa and South Dakota M.D.s and D.O.s providing services for a Wellmark member
• Out-of-state M.D.s and D.O.s who contract with Wellmark Health Plan of Iowa when the claim is for a Wellmark Health Plan of Iowa member

Claims for members covered by self-funded group health plans are not eligible for the external review process.

Qualifying physicians will receive a provider postservice appeal response letter noting that they may request a medical necessity, experimental, or investigational external review.

To request a medical necessity, experimental, or investigational external review, physicians must request the review within 60 days of the date of Wellmark’s postservice provider appeal decision.

Submit requests for a medical necessity, experimental, or investigational external review to MRIoA:

• Online – via MRIoA Medical Necessity, Experimental, or Investigational Review Web . Submit the Medical Necessity, Experimental, or Investigational external review referral and pay the accompanying filing fee online.
• By Fax or Mail – Download the Medical Necessity, Experimental, or Investigational Resolution Referral Form . Fill out and submit the form with appropriate supporting information to MRIoA:

Medical Review Institute of America, Inc.
P.O. Box 25547
Salt Lake City, UT 84125
Fax: 801-261-3189

Filing Fee

You are required to submit a filing fee with medical necessity, experimental, or investigational referrals.

• If the amount in dispute is less than $1,000, the filing fee is $50.
• If the amount in dispute is more than $1,000, the filling fee is $250.

You can pay MRIoA:

• Via MasterCard, Visa or Discover credit or debit cards on MRIoA's secure Web site
• Via check. Physicians or physician groups may remit the filing fee to:
  • Medical Review Institute of America, Inc.
    P.O. Box 25547
    Salt Lake City, UT 84125

Once MRIoA obtains the medical necessity, experimental, or investigational external review request and appropriate filing fee, MRIoA will contact Wellmark and request appropriate documentation relating to the medical necessity, experimental, or investigational determination. Wellmark has 10 days to provide the requested information to MRIoA. MRIoA will make a decision no later than 30 days after receiving the documentation necessary for the review, and will notify the physician/physician group and Wellmark.

If MRIoA issues a decision that requires Wellmark to pay the physician/physician group, Wellmark will make the payment within 15 days of being notified about the decision.

External Review Determinations Annual Report – Medical Necessity, Experimental, and Investigational Reviews

You may access a yearly, aggregate report that identifies the number of medical necessity, experimental, and investigational adverse determinations referred for external review. The report includes the percentage of adverse determinations upheld or reversed.

• 2009 Report – Note: No external review requests were submitted.

Frequently Asked Questions

How will the new appeal process change the provider inquiry process?
While you will still be able to make a provider inquiry the same way you always have, the next level of review is a more formal appeal. You may file an appeal after you have made a provider inquiry, and received an answer. The appeal is examined by Wellmark staff who were not involved with the initial decision or review.

How do I know if I’ve exhausted the provider inquiry process?
If your initial provider inquiry is not resolved to your satisfaction, and new information is available, you may submit a second inquiry with the additional information. If no additional pertinent information is available, you have exhausted the provider inquiry process and may submit a formal provider appeal for a subsequent review.

I had a claim reviewed earlier this year. Can I submit an appeal now?
If your initial provider inquiry is not resolved to your satisfaction, you may submit an appeal, as long as the request is received by Wellmark within 180 days of the remittance date of the claim in question.

How do I know if one of my claims is eligible for the external review process?
If you file an appeal, you will receive written notification of the results of the review within 30 calendar days of receipt of your request. Wellmark will include a notice with the appeal decision of the availability of this option if you are eligible. This notice will include information about how to file the appeal, and the fee for filing.