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Appeals and Disputes

MultiPlan understands the importance of streamlined and effective processes for resolving issues. Below is a summary of the most common types of disputes that providers may encounter during the course of participating in our networks.

Both you, as a participating provider, and our Clients have the right to dispute claims repricing activity. When a problem arises, you should contact our Service Operations department at (800) 950-7040 or service@multiplan.com as soon as possible, as required by your contract, to provide all information pertinent to the problem. If the issue can't be resolved through the initial call or e-mail, it will be escalated to a provider service representative who will conduct an inquiry, contacting the client and/or MultiPlan provider service representative as appropriate. The average time it takes to resolve escalated issues is less than five days.

Pre Payment Disputed Claims.

  • If you discover that you have sent an erroneous claim, you must notify the Client within sixty (60) days of the date the claim was issued.
  • If a Client receives a claim that is not a Clean Claim containing all complete and accurate information required for adjudication or if the Client has some other stated dispute with the claim, they will provide you with written notification within thirty (30) business days of receipt of the claim and prior to payment of the claim. The Client will pay or arrange to pay you at the Contract Rate(s) for all portions of the claim not in dispute. Please provide complete and accurate information requested within thirty (30) business days of the Client's request. They will pay or arrange to pay for Covered Services within thirty (30) business days of receipt of the additional and/or corrected information.

Post Payment Disputed Claims. Unless otherwise required by law, you or the Client may challenge payments made to you during the twelve (12) months following your receipt of payment from the Client, otherwise such payment shall be deemed final.

Appealing Credentialing and Termination Decisions

As a participating provider, you have the right to appeal credentialing or termination decisions made by MultiPlan. MultiPlan complies with all state and federal mandates with respect to appeals for providers terminated or rejected from the PHCS Network and/or The MultiPlan Network. Terminated or rejected providers may submit a request for an appeal as outlined in the letter of rejection/termination sent by MultiPlan. This request for appeal must be received by MultiPlan within thirty (30) days of the date of the rejection/termination letter. Upon receipt of the letter by MultiPlan, the appeal is forwarded to the MultiPlan Appeals Committee for review.

The appeal is conducted on the basis of any written information submitted by the terminated or rejected provider, in conjunction with any information previously in possession of, or gathered by, MultiPlan. Unless required by state or federal law, MultiPlan does not offer meetings in person or by telephone with the terminated or rejected provider, or any representative thereof, as part of the appeals process. In the event that MultiPlan upholds a decision to terminate a provider upon appeal, the original effective date of the termination is upheld unless otherwise determined by the MultiPlan Appeals Committee. If the Appeals Committee reverses a termination decision, the provider's participating status is reinstated as of the date of the initial adverse decision, unless otherwise determined by the Appeals Committee.

Additional information regarding the appeals process can be found in the Participating Professional Handbook.