Claims Review Process

Review/Adjustment is the first level review of a processed claim whenever a provider does not agree with the outcome and feels the claim warrants an adjustment. To request review/adjustment, providers may submit a request and attach any relevant supporting documentation within 45 days of claim determination. Review/Adjustment requests can be submitted by mail or fax. Review/Adjustment requests may also be made over the phone by calling Customer Service at (866) 937-2786.

To submit a refund, providers may use the Refund form. Complete a separate form for each patient/member. Along with the form, please include the check(s) to be refunded and a copy of the remittance notice. Please make checks payable to Community Care, Inc.

If you disagree with a claim decision, you have the right to appeal. Providers are encouraged to submit a review/reopening request before submitting an appeal, however this is not required. Formal appeals must be submitted in writing within 60 calendar days of the initial claim determination. Non-contracted providers must include a signed Waiver of Liability Form which holds the enrollee harmless regardless of the outcome of the appeal. Appeals must be clearly marked "APPEAL", and contain the provider name, date of service, date of billing, date of rejection and reason(s) claim should be reconsidered. Community Care must respond in writing within 45 calendar days of receipt of appeal.