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GRIEVANCES/APPEALS

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APPEALS
Step 1: File a reconsideration request to Optum. Once a provider has established that a denied claim should have been paid (by referencing the Maryland PBHS Billing Appendix) the provider should contact the call center at 1-800-888-1965 to dispute the denial. If the provider disagrees with the results of the call and continues to receive a denial, then they may file an appeal. Documentation* for a denial reconsideration request that shows the denial was incorrect, should be sent to Optum by either:

  • Fax to 1-844-913-0799
  • Mail to Optum Maryland: ATTN Grievances and Appeals Department, P.O. Box 30532, Salt Lake City, UT 84130.

 
Step 2: Filing a grievance to the BHA for an Optum denied reconsideration. If Optum upholds the initial denial (in Step 1), and the provider disagrees with Optum’s decision, then the provider may file a grievance to the Behavioral Health Administration (BHA) in writing within 10 days of notification of Optum Maryland’s decision by: 

  • Email to BHA.Appeals@maryland.gov (preferred), or
  • Mail to Behavioral Health Administration, ATTN: Grievances and Appeals, Spring Grove Hospital Center - Vocational Rehabilitation Building, 55 Wade Avenue, Catonsville, MD 21228.

 
Step 3: Appeal to the Maryland Office of Administrative Hearings (OAH) If the provider disagrees with BHA’s decision on a Provider grievance of a denied claim (step 2), the provider may appeal in writing within 30 days of BHA’s decision to the Maryland Office of Administrative Hearings (OAH).
 
If a Medicaid participant wishes to appeal the BHA’s decision, he or she must file a notice in writing to the Office of Health Services within 90 business days of BHA’s decision to not authorize services. Request for appeal hearings should be submitted by mail to:

  • Maryland Department of Health Office of Health Services Attention: Appeals Coordinator 201 West Preston Street, Room 127 Baltimore, Maryland 21201

The appeals coordinator will receive the materials and transmit the request to the Office of Administrative Hearings, an independent State agency.

 

 

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