Claim Reconsideration and Dispute Resolution

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Claim Reconsideration and Dispute Resolution Standards

ERISA appeal rights typically belong to the member and not providers unless specifically authorized by the member in accordance with the member’s plan requirements.

BHN provider disputes regarding post-service claims will be resolved through the dispute resolution process as opposed to the member’s plan’s claims and appeals procedures. An exception to this standard is when the provider is specifically designated as the member’s authorized representative in accordance with the member’s plan’s specific requirements for that purpose.

Note: An assignment for purposes of payment will usually not constitute a valid appointment of an authorized representative.

Dispute Resolution for Post-Service Claims

If a provider does not agree with how a post-service claim was processed (paid, corrected, denied, etc.), the claim can be submitted for reconsideration.

Claim reconsideration requests should be submitted within 60 days from the date of payment or denial of the original claim, unless the provider participation agreement states otherwise.

How to Submit for Reconsideration

Include these items in a submission:

  • The reasons the decision is contested
  • A copy of the denial letter, notice of adverse determination, Remittance Advice or Explanation of Benefits
  • The original claim
  • Documents that support the provider’s position (e.g., medical records and office notes)

Reconsideration requests can be submitted by mail only at:

MagnaCare products:
P.O. Box 8085
Garden City, NY 11530
Attention: Claim Reviews

Create products:
Create® Claim Reviews
P.O. Box 8118
Garden City, NY 11530

For more information, call Provider Services:

MagnaCare products: 800-352-6465
Create products: 844-427-3878

Decision Timeframe

If a proper submission is made, BHN will reach a decision on a post-service claim in sixty (60) days, and fifteen (15) days for a pre-service claim.

There are situations when additional documents are required to reach a decision. If requests for these documents are not satisfied, the reconsideration will be denied.