What If I Don't Agree with This Decision?
If you do not participate with Jefferson Health Plans, you may request reconsideration of our denial determination. Requests for reconsideration must be submitted within 65 days of the date of this remittance advice. A signed waiver of liability (WOL) statement is required.
If I Am a Non-Contracted Provider, How Do I File an Appeal?
Mail or deliver your written appeal to the address below:
Attn: Complaints, Grievances & Appeals Unit
Jefferson Health Plans
1101 Market Street Suite 3000
Philadelphia, Pa 19107
Once we receive the signed Waiver of Liability, we must give you a decision no later than 65 calendar days after we receive your appeal request.
What Should I Include with My Appeal?
Your written request should include your name and address, the member's name and ID number, your reasons for appealing and any evidence you wish to attach. You may send supporting medical records or other information that explains why we should pay for the service.
What Happens Next?
If you appeal, we will review our decision. After we review our decision, if any of the services you requested are still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Jefferson Health Plans. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.
What If I Am a Participating Provider and Disagree with the Decision?
If you are contracted with Jefferson Health Plans, you must accept the contracted payment from the plan. If you have any questions about the decision, you can call us at 888-991-9023.
Other Resources to Help You
- Medicare Rights Center
- 1-888-HMO-9050 Toll Free
- 1-800-MEDICARE (1-800-633-4227) 24/7 TTY: 1-877-486-2048