A non-contract provider, on his or her own behalf, may request a reconsideration for a denied claim within 60 calendar days from the remittance notification date. The non-contract provider must complete and submit a Waiver of Liability (WOL) statement with the appeal, which provides that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal.
The appeal should include supporting documentation, such as a copy of the original claim or remittance notification showing the denial and must include any clinical records and other documentation that supports the provider’s argument for reimbursement.
Payment Reconsideration Request should be mailed or fax to:
Attn: Provider Appeals
P.O. Box 1222
Chicago, IL. 60606