Point32Health understands that questions or concerns may sometimes arise regarding coverage determinations or claim payments. That’s why we have established internal appeal and dispute processes designed to resolve provider concerns quickly and efficiently, without the need for external escalation.
As valued partners in the care of our members, providers are expected to use Point32Health’s internal appeals and dispute processes before utilizing other organizations that could result in delays. Allowing direct review by clinical and claims experts, our resolution pathways can expedite appeals and disputes by ensuring that your concerns are routed to and addressed by the right Point32Health team.
Utilization management (UM) appeals
As a reminder, UM appeals are appropriate when a provider disagrees with a coverage or authorization decision, including determinations related to medical necessity or prior authorization. Because they are clinical in nature, UM appeals are reviewed by Point32Health physician reviewers, and when appropriate, specialty-matched consultants.
If a coverage request has been denied in full or in part, you can request a UM appeal — either verbally or in writing — by following the steps outlined in our provider’s guide to navigating pre-service clinical appeals. (See overview of clinical appeal process below.)
When submitting your appeal, be sure to include all relevant medical records requested and keep the guide handy for future reference. Please keep in mind that for Commercial or Medicaid members, you may request a peer-to-peer discussion with a medical director prior to submitting a UM appeal.
Claims appeals and payment disputes
Claims appeals or payment disputes are appropriate when a provider disagrees with how a claim was paid or denied. Appeals may be submitted related to reimbursement amounts, denials for lack of authorization, timely filing, and other post‑service claim determinations.
If you wish to initiate a claims appeal, begin the process by completing the Claims Review Form. Our Provider Manuals detail claims appeals procedures, but you may also find our Provider Claims Appeals flyer handy. It offers a useful overview, including instructions on how to submit your appeal by line of business and tips for submission.
Point32Health’s pathways to resolution
With our established internal appeals and dispute processes, providers benefit from clear documentation and tracking of outcomes, direct communication with clinical and claims experts, and clearly defined timelines — with the aim of efficient processing and resolution.
Additional resources
You can find more information on UM appeals, claims appeals, and payment disputes in the applicable sections of our website and Provider Manuals. If you need further assistance, please contact the applicable Provider Service Center.