When all or part of an admission or outpatient service at an eligible facility is denied for failure to meet medical necessity criteria, the AmeriHealth Pennsylvania member is held harmless and cannot be billed for the denied day(s) or service(s). The facility may appeal the denial for lack of medical necessity through the process detailed below. This process is the exclusive means of resolving such disputes. Please note that facility appeals for lack of medical necessity and payment reviews for lack of preapproval may not be pursued through the member grievance or member appeal processes.

Effective February 15, 2018, the response time to communicate our decision to the facility to uphold or overturn all, or a portion, of the adverse determination will increase from 30 to 90 calendar days from receipt of the written appeal request and the complete medical record from the appealing facility. The updated process is outlined below.

Note: This change does not apply to appeals for AmeriHealth New Jersey members. The appeals process for AmeriHealth New Jersey members will remain as outlined in the Clinical Services – Utilization Management section of the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers.

Inpatient and outpatient services appeals*

Facilities must submit the appeal in writing within 180 calendar days of the notice of adverse determination.

• Inpatient services: For inpatient services, the notice is the utilization review letter.
• Outpatient services: For outpatient services, the notice is either the initial utilization review letter or the Explanation of Payment.

The written appeal request must be accompanied by the entire medical record for the case being appealed. Appeals for denials due to lack of medical necessity should be mailed to the following address:

• Facility Appeals
• P.O. Box 13985
• Philadelphia, PA 19101

Upon receipt, AmeriHealth reserves the right to conduct a preliminary review. If medical necessity is established, a claim adjustment will be processed and a determination letter will be sent to the facility. If there is no change in disposition at the time of the preliminary review, the appeal review will be conducted by an external, independent, licensed physician. The external, independent, licensed physician must be of the same or similar specialty that typically manages the care under review and must not have been involved in the initial adverse determination or facility peer-to-peer reconsideration decision. A determination letter will be sent to the facility containing the decision and detailed explanation.

The decision to uphold or overturn all, or a portion, of the adverse determination is communicated, in writing, to the facility within 90 calendar days of receipt of the written appeal request and the complete medical record. The written determination of the appeal will include the rationale for the determination. This decision is final and binding.

*Eligible facilities for inpatient services appeals include, but are not limited to, acute care hospitals, long-term acute facilities for vent weaning, and inpatient skilled nursing facilities.

Eligible facilities for outpatient services appeals include, but are not limited to, acute care hospitals, freestanding ambulatory surgical centers, and sleep centers.