Health Claim Appeal Guide

Introduction
Claims Administrator Appeals
Plan Administrator Appeals
Download Health Claim Appeal Guide [PDF 191K]

Introduction

The AlaskaCare Employee Health Plan provides members with the right to appeal the health claims and precertifications that have been denied by the claims administrator, HealthSmart (formerly Wells Fargo TPA).

If a claim or precertification is denied, in whole or in part, your Explanation of Benefits (EOB) or letter from HealthSmart (formerly Wells Fargo TPA) will explain the reason for the denial. Please refer to your Select Benefits Insurance Information Booklet for coverage information and if necessary, call HealthSmart (formerly Wells Fargo TPA) toll-free at (877) 517-6370 for further clarification. If you still feel the claim or precertification should be covered under the terms of the Plan, you may take the following steps to file an appeal.

Claims Administrator Appeals

Level I Appeal

Please submit your request in writing, explaining the nature of your appeal, including copies of EOB’s, correspondence, and pertinent medical records. Your appeal must be received by HealthSmart (formerly Wells Fargo TPA) within 180 days of the date the EOB or precertification denial letter was issued. Submit your request to the following address:

HealthSmart (formerly Wells Fargo TPA)
Attention: Member Appeal
P.O. Box 99004
Anchorage, AK 99509-9004

You will receive a written decision from HealthSmart (formerly Wells Fargo TPA) within 30 days after their receipt of your appeal. If you are not satisfied with the Level I decision and you are eligible for further appeal, you may submit a Level II appeal to HealthSmart (formerly Wells Fargo TPA). See instructions for Level II Appeal below.

Level II Appeal

HealthSmart (formerly Wells Fargo TPA) must receive your written request for a Level II appeal within 60 days of the date the Level I decision letter was issued. Your appeal will be reviewed by a panel who did not participate in the Level I review.

You will receive a written decision from HealthSmart (formerly Wells Fargo TPA) within 60 days after their receipt of all relevant information in your appeal. If you are not satisfied with their final decision, you may request a review by the Plan Administrator.

URGENT APPEALS: If your doctor or provider advises HealthSmart (formerly Wells Fargo TPA) that a delay in your appeal process could harm your health, they will reach a decision regarding your appeal within 72 hours after receipt of your Level I or Level II appeal.

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Plan Administrator Appeals

If you disagree with the final claims administrator’s decision, you may send a written request for review directly to the AlaskaCare Plan Administrator. Please include any additional relevant material with your written appeal. If you appeal to the Plan Administrator they will request a copy of your claims administrator appeal file, including any documentation from your provider for their records and review of your appeal. Please send your written request for appeal to the following address:

State of Alaska
Division of Retirement & Benefits
Attn: Health Appeals
P.O. Box 110203
Juneau, AK 99811-0203

Your request must be postmarked or received within 45 days from the date HealthSmart’s (formerly Wells Fargo TPA) final decision letter was issued. The Plan Administrator will issue a decision within 30 days after receiving all the relevant material in your appeal.

Your appeal may be sent to an Independent Review Organization (IRO). IRO is an organization of medical experts qualified to review your appeal.

The Plan Administrator will issue a decision in writing within 30 days after receiving the IRO’s recommendation.

If you are not satisfied with the decision, you may appeal to the Superior Court.

URGENT APPEALS: If the Plan Administrator is advised that your life or health is threatened by a delay in the appeal process, an emergency review may be requested. In making an emergency review, we will generally rely on the opinion of your treating physician.