Claim Appeal Rights
A Provider may dispute Lakeland Care’s payment, nonpayment, partial payment, late payment, or denial of claim by filing a written request with the Lakeland Care Business Division within sixty days of Lakeland Care’s action. The Business Division will review claims for reconsideration when submitted by a provider.
Appeals from Providers must include the following elements:
- Appeals must be clearly marked as “appeal” and addressed to the fiscal supervisor.
- Appealed claims must be received within 60 days of the Explanation of Benefits (EOB), ERA, or denial letter.
- Claims must have all the elements of a clean claim as outlined in the contract, including Provider’s name, member’s name, service description or code, date(s) of service, date of billing, date of rejection, and copy of EOB. Providers may request another copy of the letter of authorization from the Claims Customer Service Associate for the month of the claim if they do not have a copy of their original.
- Claims must include a written statement indicating the reason for the appeal. If more than one claim is being appealed each must have a reason statement or contain a cover statement indicating the reason for the appeal is the same for all resubmitted claims.
- Claims submitted as appeals will be reviewed by Lakeland Care one time only.
- Providers can further dispute an unpaid claim with DHS.