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PROCESS FLOW 1. All Scott White Health Plan claims submitted for reprocessing adjustments appeals except Right Care Medicaid Claims must be mailed to Scott and White Health Plan ATTN Claims Review Dept. Adjustment Appeal Communication Process Below you will find the steps necessary to submit a claim for reprocessing adjustments or appeals. P. O. Box 21800 Eagan MN 55121-0800 2. Provider or inquiring party must provide the information on the Provider Claims Appeal Request Form. See attachment 1 3. Should there be multiple claims in question an excel spreadsheet providing the same information as the Provider Claims Appeal Request Form is acceptable. Attach the excel spreadsheet to a copy of the Provider Claims Appeal request Form. 4. If the Claims Appeal Request Form or excel spreadsheet are not completed as requested above it will be returned to the requestor for completion* 5. The Claims Appeal Request Form received by mail will be processed within 30 days of receipt. 6. As of April 16th all request for Adjustment or Appeal must be submitted using this format or the request will be returned* Provider Claim Appeal Request Form This form should not be used for RightCare Medicaid claim appeals In order to expedite the process of your request this form is required* Please complete all of the following information for each appeal if not completed the correspondence will be returned to the provider for correction* Corrected claims are no longer accepted with this form* Please submit as a new claim to the below address. Review Submission Date Contact Name Provider Name Contact Phone Number Provider or NPI Member Name Provider Address SWHP Member ID SWHP Claim number Date Of Service Choose the Reason for Appeal that best represents your request Filing Limit Claim Check/Code Editing Contracted Rate or Payment Policy COB Data Entry Error Overpayment/Underpayment specify Other specify Please attach any pertinent supporting documentation i*e* surgical notes office visit notes pathology reports and/or medical records and mail it to the below address. Attn Provider Appeals Faxed claim requests are not accepted All Claims request for adjustment must be submitted within 45 days from the date of payment or determination by SWHP to receive consideration* These considerations will be completed timely. P. O. Box 21800 Eagan MN 55121-0800 2. Provider or inquiring party must provide the information on the Provider Claims Appeal Request Form. See attachment 1 3. Should there be multiple claims in question an excel spreadsheet providing the same information as the Provider Claims Appeal Request Form is acceptable. See attachment 1 3. Should there be multiple claims in question an excel spreadsheet providing the same information as the Provider Claims Appeal Request Form is acceptable. Attach the excel spreadsheet to a copy of the Provider Claims Appeal request Form. 4. If the Claims Appeal Request Form or excel spreadsheet are not completed as requested above it will be returned to the requestor for completion* 5.

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