Provider Claim Appeal & Resubmission

 

A claim appeal is when a claim is finalized, but a provider disagrees with the outcome and requests a review of the outcome. If a Provider Claim Appeal form is not utilized the document must include the verbiage including the word “appeal”.

Level I and II Claim Appeals

View our Level I and II Claim Appeal Request Process and Form.  
An appeal must meet the following requirements: 

  • Claim Appeals are to be submitted individually for each claim number.
  • Submit one copy of the Remit/EOB for each claim appealed. 
  • Circle the individual claim being appealed on the individual remit/EOB.
  • Indicate if this is a Level I or II Claim Appeal
  • If applicable, indicate the incorrect information and provide the corrected information that should be used to appeal the claim. 
  • Attach a copy of any supporting documentation that is required or has been requested by Parkland Community Health Plan. Supporting documentation to prove timely filing should be the acceptance report from Parkland Community Health Plan to the provider’s claims clearinghouse. Supporting documentation must be on a separate page and not copied on the opposite side of the Remit/EOB. 
  • Please submit your appeals and all supporting documentation to the following address: 
    • Parkland Community Health Plan
      Claims Appeal
      P.O. Box 560347 
      Dallas, TX 75356-9005 
    • On the Provider Portal

The status of an appeal can be viewed on the PCHP Provider Portal or by calling Provider Customer Service. A resolution will be mailed, and a copy will be accessible on the PCHP Provider Portal.  

Claim Resubmission

A claim resubmission is a claim originally denied because of incorrect coding (would be considered a corrected claim) or missing information (would be considered a resubmission) that prevents PCHP from processing the claim. 
 
The additional information (COB form, corrected claim, etc.) can be submitted: 

  • On the Provider Portal via the Claim Resubmission Form 
  • In writing with our  Claims Resubmission Form, with all supporting documentation mailed to: 
    Parkland Community Health Plan 
    Attn: Claims Resubmission
    P.O. Box 560327 
    Dallas, TX 75356 

Claims for Clients with Retroactive Eligibility 

Title 42 of the Code of Federal Regulations (42 CFR), at 447.45 (d) (1), states, “The Medicaid agency must require providers to submit all claims no later than 12 months from the date of service.” The 12-month filing deadline applies to all claims. Claims not submitted within 365 days (12 months) from the date of service cannot be considered for payment. Retroactive eligibility does not constitute an exception to the federal filing deadline.