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PROVIDER APPEALS RELATED TO CREDENTIALING, SANCTIONS OR TERMINATIONS

Providers have the right to appeal any adverse NCC decision regarding network participation. Carelon has established a Provider Appeals Committee (PAC) to hear provider appeals. This committee is comprised of representatives of major clinical disciplines, network providers and clinical representatives from corporate departments within Carelon, none of who compete with the appealing provider. Members of the PAC must not have participated in the original NCC decision under review.

Providers are given written notice of the NCC’s decision, the reason for the decision, and of their right to appeal the decision along with an explanation of the applicable appeals procedures. Providers have 30 days from the date of the NCC notice to file a written request for an appeal.

The request for an appeal should include an explanation of the reasons the provider believes the NCC decision to be in error. The PAC will review the explanation provided by the provider, the information previously reviewed by the NCC and any additional information it determines to be relevant. The PAC will support, modify or overturn the decision of the NCC. Additionally, the PAC may request additional information from the provider in order to make a determination or decision. The PAC will provide written notification of its decision to the provider within 14 business days after its record is complete, with an explanation of the decision, along with appeal rights and fair hearing rights.