Skip to main content

Appeals

Q. What is a health plan action?
A.
An action is defined as:
  • The denial or limited authorization of a requested service, including the type or level of service;
  • The reduction, suspension, or termination of a previously authorized service;
  • The denial, in whole or in part, of payment for a service;
  • The failure to provide service in a timely manner as defined by the state; or
  • The failure to act within timeframes for the health plan’s Prior Authorization review process 

Q. What is a complaint?
A. A verbal or written expression of dissatisfaction or dispute with health plan policy, procedure, claims (processing time, amount, etc. not denials) or any aspect of health plan functions. Essentially, complaints relate to anything other than a denial/health plan action. All complaints will be logged and tracked whether received by phone, in person or in writing.

A complaint is the first level of the complaints and appeals process.

Q. What is the procedure for filing a complaint?
A.
Providers may file a verbal or written complaint with the Missouri Care Complaints and Appeals Department. Complaints should be addressed to:  

Missouri Care Health Plan
Attn: Appeals
4205 Philips Farm Road, Suite 100
Columbia, MO 65201
573-441-2100 or 1-800-322-6027 

Q. How long do I have to submit a complaint?
A.
Complaints must be submitted within ninety (90) calendar days of the incident that resulted in the complaint.

Q. What is Missouri Care's timeframe for responding to a complaint?
A.
All complaints will be resolved within thirty (30) calendar days of receipt of the complaint at the health plan. At the time of Missouri Care's complaint decision, the provider will receive a written notification of the decision and their right to file an appeal. 

Q. What is an appeal?
A. The mechanism which allows the right to request review of health plan actions to a provider who:

  • Has a claim or request for authorization denied or not acted upon with reasonable promptness; or
  • Is aggrieved by any rule or policy or procedure or decision by the health plan.

An appeal is the second and final level of the complaints and appeals process. All expressions of dissatisfaction resulting from receipt of a claim or authorization denial are automatically classified as an appeal. 

Q. What is the procedure for filing an appeal?
A.
Providers may file a written appeal with the Missouri Care Complaints and Appeals Department. Appeals should be addressed to:

 Missouri Care Health Plan
Attn: Appeals
4205 Philips Farm Road, Suite 100
Columbia, MO 65201

Q. How long do I have to submit an appeal?
A.
Appeals must be submitted in writing within ninety (90) calendar days of the service or claim denial date. The service denial date is the date of the notice of action/denial letter forwarded from the prior authorization department. The claim denial date is the date of the remittance advice. Both the notice of action and the remittance advice include information regarding appeal rights and submission procedures. 

Q. What is Missouri Care's timeframe for responding to an appeal?
A. All appeals will be resolved within thirty (30) calendar days of receipt of the appeal at the health plan. The provider will receive a written notification of Missouri Care’s appeal decision. 

Q. What number should I call to check status of a complaint or appeal?
A.
To confirm receipt or check status of a complaint or appeal providers may contact Claims Information & Claims Research at 1-800-322-6027 (option 2, option 3). 

Q. How does Missouri Care review an appeal/complaint?
A.
Each complaint or appeal is reviewed based on the unique merits of the case. Missouri Care’s reviewers consider the distinctive characteristics and circumstances of each case as presented in the appeal letter and supporting documentation, as well as internal documentation applicable to the case (i.e. claim system edits, payment policies, correct coding guidelines, prior authorization notes, medical necessity criteria, etc.) As such, it is in the provider’s best interest to clearly state in the complaint or appeal letter their position/rationale, specific to each denial or incident.

Q. If the appeal decision is overturned, how long before my claim is reprocessed?
A.
Missouri Care seeks to reprocess overturned claims within 30–45 days from the appeal resolution.

contact-us

Need help? We're here for you.

Contact Us
Last Updated On: 3/4/2019
On April 1, 2019, Missouri Care will transition to LIBERTY Dental Plan for all of your dental services. Your dental benefits will not change with the switch to LIBERTY Dental. If you have any questions, contact Missouri Care Member Services at 1-800-322-6027. ×