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 How to Appeal a Medical Claim 

PEIA PPB Plan

If you are a PEIA PPB Plan participant or provider and think that an error has been made in processing your claim or reviewing a service, the first step is to call HealthSmart, the Third Party Administrator, to verify that a mistake has been made. All appeals must be initiated within 60 days of claim payment or denial.

Type of Error	Who to Call	Where to Write
Medical claim denial	HealthSmart  1-888-440-7342	HealthSmart  P. O. Box 2451  Charleston, WV 25329-2451
Out-of-state care denial, denial of  pre-certification or case management	ActiveHealth  1-888-440-7342	ActiveHealth Management  PO Box 221138  Chantilly, VA 20153-1138
Prescription drug claim	Express Scripts  1-877-256-4680	Express Scripts, Inc.  Clinical Appeals - (Client-WVA)    BL0390  6625 W. 78th St., Bloomington, MN   55439

If your medical claim or service has been denied, or if you disagree with the determination made by one of the Third Party Administrator, the second step is to appeal in writing within 60 days of the denial to the Third Party Administrator at the address listed above. Explain what you think the problem is, and why you disagree with the decision. Please have your physician provide any additional relevant clinical information to support your request. The Third Party Administrator will respond to you by reprocessing the claim or sending you a letter.

If this does not resolve the issue, the third step is to appeal in writing to the director of the PEIA. The participant, provider or covered dependent must request a review in writing within sixty (60) days of getting the decision from the Third Party Administrator. Facts, issues, comments, letters, Explanations of Benefits (EOBs), and all pertinent information about the case should be included and mailed to:

Director
Public Employees Insurance Agency
601 57th St., SE, Suite 2
Charleston, WV 25304-2345

When your request for review arrives, the PEIA will reconsider the entire case, taking into account any additional materials which have been provided. A decision, in writing, explaining the reason for modifying or upholding the original disposition of the claim will be sent to the insured or his or her authorized representative. If additional information is required to render a decision, this information will be requested in writing. The additional information must be received within 60 days of the date of the letter. If the additional information is not received, the case will be closed.

Managed Care Plan Members

If you are a managed care plan member, and you think that an error has been made in processing your claim, the first step is to call your managed care plan to discuss the matter.

If your claim has been denied, or if you disagree with the determination made by your managed care plan, the second step is to appeal in writing within 60 days of the denial to your managed care plan. Instructions for filing that appeal are in your “Evidence of Coverage” provided by your managed care plan.

If you are not satisfied with the response from your managed care plan, you may appeal in writing to the director of the PEIA. You or your covered dependents must request a review in writing within sixty (60) days of getting the decision from your managed care plan. Facts, issues, comments, letters, Explanations of Benefits (EOBs), and all pertinent information about the claim and review should be included. The appeal should be mailed to:

Director
Public Employees Insurance Agency
601 57th St., SE, Suite 2
Charleston, WV 25304-2345

When your request for review arrives, the PEIA will reconsider the entire case, taking into account any additional materials that have been provided. A decision, in writing, explaining the reason for modifying or upholding the original disposition of the claim will be sent to the insured or his or her authorized representative.

If additional information is required to render a decision, this information will be requested in writing. The additional information must be received within 60 days of the date of the letter. If the additional information is not received, the case will be closed.

If you disagree with the decision of the PEIA director, you have one final level of appeal to the West Virginia Insurance Commissioner. Instructions for this appeal are also provided in your “Evidence of Coverage” from your managed care plan.