Peach State Provider Office Manual - Peach State Health Plan ...

selected, unless the plan and the provider mutually agree to extend this deadline. All costs ofarbitration, not including attorney’s fees, shall be shared equally by the parties.You must exhaust all of the Plan’s internal Provider Complaint Processes prior to requesting anAdministrative Law Hearing. All arbitration costs will be shared by the Plan and the ProviderRequests should be mailed to:Peach State Health PlanAttn: Manager, Grievance & Appeals3200 Highlands Parkway Suite 300Smyrna, GA 30082Outlier AppealCriteria for Outlier DRG Calculation:(a) A case meets the outlier DRG criteria when it meets two (2) conditions:1. It would normally be paid through the inlier DRG payment mechanism.2. The operating cost of the case is more than the assigned DRG cost threshold(b) In addition, a hospital must request that a claim be reviewed to assess manually if it meets theabove two (2) conditions.All requests for outlier appeal consideration must be submitted in writing and received withinthree (3) months of the month in which the initial payment was made (date of the initial EOP onwhich the claim appears). If the request and all required documentation are not received by theplan within three (3) months from the end of the month of the initial EOP payment, the outlierreconsideration request will be denied for failure to request payment reconsideration in a timelymanner.Facilities requesting outlier payment consideration must submit the following documents with the request:• A cover letter indicating the request is for outlier appeal consideration and please include acontact person, physical address (for mailing purposes), and phone number for eachcase• A copy of the original claim and an itemized bill• A copy of the EOP on which the original claim appears• All requests for outlier consideration will process in a timely manner. Notification of thedecision will appear on the EOP or a letter if the claim does not qualify for outlierconsideration.Provider Services1-866-874-063302/22/201194