Appeals

Index

• The Appeals Process

  • For Providers

  • For Members

  • Timely Filing

  • Appealing Review Determinations

  • Appealing Rescission Determinations

• Appeals Status Flow Chart

  • Step 1: Collect & Verify Member Information

  • Step 2: Collect Claim Information

  • Step 3: Verify Appeal Receive Date

  • Step 5: Offer to Resend Response Letter

  • Step 5 (Alternative): Check Days Since Received

• Appeals to Legal Decision Tree

The Appeals Process

For Providers

To appeal a claim, providers should mail or fax the appeal to:

Insurance Benefit Administrators
PO Box 2917
Shawnee Mission, KS 66201
Fax: 913-901-0534

For Members

To appeal a claim, members should email Client Services with:

• Member’s name

• Member ID number

• Claim number

• Explanation of why determination is believed to be wrong

• Any supporting attachments (e.g., medical records)

 

Timely Filing

• Appeals must be filed within 180 days of the claim’s process date.

Appealing Review Determinations

• Follow the same process as claim appeals.

• Include the review ID instead of claim numbers.

Appealing Rescission Determinations

• Process varies by carrier.

• Appeals go to the carrier, not Allied.

• Direct members back to their rescission letter for specific instructions.

Appeals Status Flow Chart

Step 1: Collect & Verify Member Information

• Ask:

  “Can I please have your ID number?”
  “May I have your name and date of birth?”

Step 2: Collect Claim Information

• Ask:

  “Can you provide me with the claim number related to your appeal?”

Step 3: Verify Appeal Receive Date

• Check whether the appeal has been logged.

If the appeal is missing:

1. Verify information again.

2. Advise: “The appeal is not on file.”

3. Provide the appeals mailing address, fax, or email.

Step 4: Offer to Resend Response Letter (If Response Letter Exists in AI)

• Say:

  “It looks like we sent a response on [date]. Would you like me to send that response to you now?”

Step 5 (Alternative): Check Days Since Received (If No Response Letter Found)

• If >45 days:

  • Say:

    “It generally takes 30–45 days to process an appeal. Please allow a little more time.”

• If <45 days:

  • Open with claims team for next steps.

Appeals to Legal (decision Tree)

• Never provide the address where an appeal response was sent.

• Always ask caller to confirm the address they used.

• Follow the Legal decision tree exactly.