Fidelis SecureCare of North Carolina Provider Manual

Claim Disputes and Appeals
Appealing an Organization Determination
The appeal process for contracted practitioners or providers applies to UM denial
determinations that are adverse for the practitioner or provider, but not adverse to the
member. The UM team assumes that the practitioner or provider is acting strictly on
his/her own behalf when requesting the appeal when the member has no financial risk
for the service denied.
Examples of UM denial determinations included in the scope of this policy include:
• Contracted provider appeal of denied standard pre-service request, member has
not received the requested service, therefore has incurred no financial risk
• Contracted provider appeal of denied post service request, member is not
financially at risk, i.e. denied inpatient admission at a contracted facility
The contracted provider must submit the appeal request in writing to the following:
Email: appeals@fidelissc.com
Mail: Fidelis SecureCare
Appeals Dept.
20 N. Martingale Road, Suite 180
Schaumburg, IL 60173
The written request must include supporting medical documentation. This
documentation will be reviewed by the Medical Director and a written determination will
be mailed within 30 days of the receipt of the appeal. This determination will be final.
Claim Disputes
Providers have the right to dispute the manner in which the claim was processed or
paid. There are two levels to the provider dispute process:
Provider Dispute (Verbal)
The provider can contact the claim inquiry call center at 877-372-8085. The claims team
will review the provider dispute and either re-process the claim or uphold the claims
processing determination. The provider will be notified of the determination via returned
call or updated remittance advice report. Second level claim appeals may be sent via
the address or email listed above.
Claim Disputes and Appeals