Providers: Updated Provider Manual – Section 14, Provider Credentialing

Posted 8 July 2010 by egatton & filed under Newsroom, Provider News.

The MHS Provider Manual  Section 14, Provider Credentialing  - Network Practitioner, Provider Appeal of Suspension or Termination of Contract Privileges has been updated. This update includes:

Network Practitioner/Provider Appeal of Suspension or Termination of Contract Privileges

If a Network Practitioner/Provider has been suspended or terminated by Managed Health Services, he/she may contact the Managed Health Services Provider Relations department at (800) 222-9831 to request further information or discuss how to appeal the decision.

For a formal appeal of the suspension or termination of contract privileges, the Network Practitioner/Provider should send a written reconsideration request to Managed Health Services to the attention of the Credentialing Department:

Managed Health Services
Attn: Credentialing Department
10700 W. Research Drive, Suite 300
Milwaukee, WI 53226

Please note that the written request should describe the reason(s) for requesting reconsideration and include any supporting documents. This reconsideration request must be postmarked within thirty (30) days from the receipt of the suspension or termination letter to comply with the appeal process.

Providers are given the opportunity for two levels of appeal hearing. The first-level consists of an Appeals Committee, a panel of three peers that will review the credentialing committee’s determination. Peers are defined as a provider with the same licensure, and at least one participating provider (in network), not necessarily of the same specialty as the requesting provider, and were not involved in the initial credentialing determination. The hearing will be scheduled as soon as possible, no later than 6 months from the request. The Appeals Committee’s determination will be communicated to the provider in writing detailing the rationale for the decision, and further appeal rights that includes the procedure for requesting a second-level appeals hearing, if applicable.

At the conclusion of the first-level appeal hearing the provider will be given the right to request a second-level appeal hearing. The second-level appeal hearing is conducted by Managed Health Services Board of Directors. The Board of Directors consists of at least three individuals that were not involved in the first-level panel. The Board of Directors shall review the recommendation of the Appeals Committee and provide a final determination. The determination will be communicated to the provider in writing detailing the rationale for the decision.

MHS Provider Manual, updated 7/07/10 (PDF) (p. 107-108)

MHS’s Provider Relations department is available at: (800) 222-9831.