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Claim Reconsideration

A provider can request a reconsideration determination for a claim that a provider believes was paid or denied incorrectly, whether the result of a provider billing error or a Jefferson Health Plans/Health Partners Plans processing error. Providers should request the reconsideration of a claim using the provider portal.

Rear view of a doctor walking down a hallway holding some papers

All claim reconsideration requests must be received within 180 calendar days from the date of the Explanation of Payment (EOP) advising of the adjudication decision. Claim reconsideration requests should include a copy of the EOP and any other documentation supporting the assertion that the claim was paid incorrectly or why the denial should be overturned. Other important points to remember:

  • If the claim involves other insurance, information regarding the member’s primary insurance coverage must be provided, such as a primary EOP/Primary Insurance Denial Letter.
  • If the claim was denied for lack of an authorization or services not matching the authorization, the provider must contact the appropriate utilization management area to address the authorization problem and, only when resolved, submit a claim reconsideration request. Denials such as these are not handled by the Claims Reconsideration department. The dispute with the authorization needs to be reviewed and handled by the Utilization Management department. Appeals for denied authorizations or lack of inpatient authorizations should be sent to the Utilization Management department at:

    Health Partners Plans/Jefferson Health Plans
    Attn: Inpatient Provider Appeals
    1101 Market Street, Suite 3000
    Philadelphia, PA 19107

    Email: appeals@jeffersonhealthplans.com

  • If the claim was denied because the provider is non-participating and lacked authorization, and the provider believes he or she is participating, there may be a problem with credentialing. We must be contacted and this issue resolved before the claim can be reconsidered. Please contact us for assistance at 1-888-991-9023 to verify provider identification numbers. Claims denied because the requested authorization or level of care was not approved constitute a medical necessity disagreement.

When requesting a claim reconsideration for multiple claims with the same denial reason, please ensure that all affected claims are listed on the approved claim submission spreadsheet. The template can be found here.

The best practice for a claim reconsideration request should be to submit a ticket through the provider portal. However, if a provider still has questions regarding the status of an appeal denial/response, they can reach out to the Provider Services Help Line at 1-888-991-9023.