A claim is considered denied when a request for payment is received as clean and processed by Vaya Health, but the request does not meet all required criteria for approval of payment. A clean claim is one that can be processed without obtaining additional information from the provider or a third party.
Notifications of claim denials are provided by the remittance advice (RA) or by other final notification of payment, payment denial, disallowance, payment adjustment or notice of program or institutional reimbursement. Final notification occurs after all administrative actions by the provider, along with assistance from Vaya, have been applied to the claim in an attempt for the claim to be paid and the claim has denied, in whole or in part. All providers must submit requests for reconsideration of claims denials within 30 days of this final notification.
Submitting a reconsideration request
To request reconsideration of a claim, providers must complete the Claims Denial Reconsideration Request Form (Level 1). The submitted form must include all claim(s) specifics, including, but not limited to, the member’s name, member record number, date of service, service code, claim header information, RA and any other relevant information deemed necessary for identification of a specific claim. All fields must be completed for the request to be accepted.
Level 1 requests undergo a desk review process. Vaya will schedule a Level 1 Desk Review panel meeting within 60 days (not including paid holidays) from the receipt of the signed, complete and timely Level 1 form, unless there are documented extenuating circumstances for you or for Vaya.
Following the desk review, a decision will be made to uphold, overturn, adjust or determine that more information is needed. The panel will issue this written decision within 60 days of the date of the Level 1 Desk Review. The panel may request additional time to issue the decision if necessary or may request a Level 2 meeting to receive more information about the claim.
If a signed and completed Level 1 form is not received within the required 30-day period, Vaya’s action to deny the claim becomes final without further written notification.
What if I disagree with the Level 1 decision?
Providers who are dissatisfied with the Level 1 reconsideration decision may submit a written request for a Level 2 reconsideration review. The form to request Level 2 reconsideration will be attached to the Level 1 reconsideration decision. You must submit a signed and complete Level 2 form within 30 days of the date of the Level 1 decision.
In the Level 2 form, you must specify whether you will participate in the Level 2 reconsideration review in person, by telephone or by submitting additional documentation. All documentation for review must accompany your request.
If a signed and complete Level 2 form is not received within the required 30-day period, Vaya’s decision becomes final without further written notification, unless the panel previously determined more information was needed during the Level 1 Desk Review.
When will the Level 2 panel meeting be scheduled?
Vaya will schedule a Level 2 Desk Review panel meeting within 30 days (not including paid holidays) from the receipt of a signed, complete and timely Level 2 form, unless there are documented extenuating circumstances for you or for Vaya. If you do not attend the Level 2 meeting (in person or by phone) or do not submit additional documentation as previously arranged, the Level 2 reconsideration will be dismissed, and the Level 1 decision will become final.
Following the Level 2 review, a decision will be made to uphold, overturn or adjust the Level 1 decision. The panel will issue a written decision within 30 days from the date of the Level 2 Desk Review. The Level 2 decision is final and may not be appealed further with Vaya.