How to submit your reconsideration or appeal Oxford Level-Funded plans (NJ and CT) - 2021 Administrative Guide
If you disagree with claim payment issues, overpayment recoveries, pharmacy, medical management disputes, contractual issues or the outcome of your reconsideration review, send a letter requesting a review to:
Oxford Level Funded members:
Grievance Administrator
P.O. Box 31393
Salt Lake City, UT 84131-0371
Standard Fax: 1-801-478-5463
Time frame
You must submit your claim reconsideration and/or appeal to us within 12 months (or as required by law or your Agreement), from the date of the original EOB or denial. The two-step process allows for a total of 12 months for timely submission, not 12 months for step one and 12 months for step two.
What to submit
As the care provider of service, you submit the dispute with the following information:
- Member’s name and health plan ID number
- Claim number
- Specific item in dispute
- Clear rationale/reason for contesting the determination and an explanation why the claim should be paid or approved. If you disagree with the outcome of the claim appeal, you may file for an arbitration proceeding. A description of this process is in your Agreement.
Refer to Claim Reconsideration and Appeals Process section in Chapter 10: Our Claims Process, for more information.