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Facility Dispute Resolution Procedure
- This procedure describes the exclusive method of initiating any disputes related to HealthChoice Network Facility Contracts and Network Provider Acute Care Facility Contracts. The submission of a Request for Dispute Resolution Form to HealthChoice will signify good faith acceptance and agreement with all of the terms herein.
- The initiation of a dispute shall not require a party to delay or forego taking any action that is otherwise permitted by the network contract.
- HealthChoice has adopted this policy to provide a consistent method for the resolution of disputes with network facilities.
- Facilities who wish to dispute a decision by the HealthChoice Appeals Unit can submit a Request for Dispute Resolution within 45 days of the Appeals Unit’s final adverse determination. If not timely filed, the request will not be considered, and the matter will be deemed finally resolved. HealthChoice will have 45 days after submission to reach a determination.
- All Requests for Dispute Resolution must be submitted with a properly completed HealthChoice Request for Dispute Resolution Form. Forms must be mailed to HealthChoice at the address shown on the Form. Requests involving multiple similar claims must be accompanied by a spreadsheet including pertinent information on all claims. Requests submitted with insufficient supporting documentation will be returned.
- HealthChoice will not discriminate or retaliate against any facility due to participation in the Dispute Resolution process. All rights and conditions set out in the network facility contract will apply to the parties at all times, regardless of the existence of a Request for Dispute Resolution between the parties.
- Facilities are not permitted to pursue dispute resolution on behalf of a member or dependent. Facilities have agreed by contracting with HealthChoice that the permitted and non-permitted matters subject to this dispute resolution procedure are limited and listed in the network facility and Network Provider Acute Care Facility contracts at Section X. Dispute Resolution, paragraph 10.1. Facilities are not permitted to pursue, initiate or continue this dispute resolution process when the member or dependent timely exercises or has exercised their legal right to appeal the same claim or service that gives rise to the dispute specified by the facility.