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:
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:
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:
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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