Managed Care

Guidance/Policy on hearing process after appeal of denial (NCQA)

  • 1.  Guidance/Policy on hearing process after appeal of denial (NCQA)

    Posted 06-22-2016 02:33 PM

    Hello! We are preparing to allow for a hearing to appeal a denial decision according to NCQA CR7, Element A, Factor 3: Appeals Process

    • Allowing practitioners to request a hearing and the specific time period for submitting the request.
    • Allowing at least 30 calendar days after the notification for practitioners to request a hearing.
    • Allowing practitioners to be represented by an attorney or another person of their choice.
    • Appointing a hearing officer or a panel of individuals to review the appeal.
    • Written notification of the appeal decision that contains specific reasons for the decision

    Has anyone completed a hearing and, if so, would you mind sharing your process for conducting the hearing and any suggestions/tips?

    Thank you!

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    Tiffany Marcks
    Internal Compliance Auditor
    Examination Management Services, Inc
    Irving,TX
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