Provider Courtesy Review Process

DMBA administers plans that offer only plan participants, beneficiaries, or their authorized representatives the right to appeal an adverse benefit determination. However, if a provider disputes post-adjudicated claims related to medical necessity, billing/coding, and no preauthorization for an inpatient stay, a provider may request a courtesy review of the claim without written authorization from the participant. Only one courtesy review per claim will be available to the provider.

The provider must submit a written request for a courtesy review within 12 months from the date the claim was processed, using the Provider Review Form . Because this form will continue to be updated from time to time, we recommend the provider print the form from the website each time to ensure that the most up-to-date version is being used.

As part of the review, the provider must specify in detail the reason(s) for requesting a review of the benefit decision. Copies of all documents that support the provider's position should also be included, such as medical or dental records, operative reports, bills, explanation of benefits (EOBs), X-rays (dental procedures only), doctors' letters, etc.

Send the request to:

Pre-service Urgent Claims

In the case of a pre-service claim involving urgent care, the treating physician may request an urgent appeal on behalf of the participant, using the Member Appeal Form and marking the Urgent Care Information box, for any pre-service claim for medical care or treatment that requires a benefit determination before the applicable benefit determination timeframes because:

1. It could seriously jeopardize the life or health of the participant or the ability of the participant to regain maximum function; or
2. In the opinion of a physician with knowledge of the participant’s medical condition, it would subject the participant to severe pain that cannot be adequately managed without the care or treatment that is subject of the claim.

If DMBA determines that the pre-service claim meets the urgent claim definition, DMBA will process the request as an urgent claim as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim.

Procedures or treatments that have already been provided to the participant do not qualify for consideration as an urgent claim. A request for preauthorization of a service or benefit that does not require preauthorization approval under the plan requirements is not a claim for benefits and is not eligible for review.