Reconsideration and Reassessment Process

The hospital or physician may request a reconsideration or reassessment of an adverse determination. Third party hospital contractors may request the reconsideration on their behalf and submit information; however, all notifications and conversations will be directed to the designated hospital personnel and/or treating physician only.

  • CLICK HERE for a QUICK GUIDE on how to submit a reconsideration request.

PLEASE CLICK BELOW ON THE APPROPRIATE REQUEST FORM:

  • CLICK HERE for a copy of the Reconsideration Process Presentation

 Important Third Party Notice: As we conveyed in our Provider Notice dated May 11, 2010, third-party contractors may request a reconsideration and submit information on behalf of the hospital or physician; however, as contracted by the Department of Healthcare and Family Services, all eQHealth notifications and conversations are directed to the designated hospital personnel and/or treating physician.

What is an Expedited Reconsideration?
Is available for denials rendered by a physician reviewer during admission or concurrent reviews, and requested while the patient is still hospitalized. This is beneficial if pertinent information fully supporting the medical necessity of the denied day(s) was mistakenly ommitted from the review request. The hospital or physician may send the request, in writing, along with a copy of the medical record for the date(s) of denial or any pertinent clinical information to substantiate medical necessity. This can be sent via fax or overnight service. See methods of submitting reconsiderations below.

What is a Standard Reconsideration?
Is available for denials rendered by a physician reviewer during admission, concurrent or retrospective prepayment reviews. The hospital or physician may submit the reconsideration request within 60 calendar days of the Notice of Denial. The request must be submitted in writing, along with a copy of the medical record for the date(s) of denial or pertinent clinical information necessary to substantiate medical necessity.

What is a DRG Reassessment?
A DRG reassessment may be requested after a physician reviewer determines that the billed principal diagnosis, secondary diagnoses, and/or procedural coding is inconsistent with the documentation in the medical record and has resulted in revision of the DRG assignment. The hospital or physician may send in a request for DRG Reassessment with supporting documentation to support the billed DRG within 60 calendar days of the Notice of DRG Change.