Table 21-12, Facility Retrospective Review Request

FOR DENIALS BASED ON "NO PRIOR APPROVAL"

FOR DENIALS BASED ON "NO E.R. NOTIFICATION"

BENEFIT PLAN(S)

WHAT/HOW/WHERE TO FILE INSTRUCTIONS

TIME FRAMES*

ADDITIONAL RIGHTS

Initial Facility Filing

ConnectiCare Determination Notification

Commercial

Unless otherwise directed in the denial letter, write to:

ConnectiCare (Commercial) Attention: Provider Appeals

175 Scott Swamp Road, Farmington, CT 06032-3124

Telephone:
800-251-7722

Per contracted facility time frames in provider agreements

Notification of determination is made within 30 days from receipt of the necessary information.

May file a facility clinical appeal.

 Medicare

Write to:

ConnectiCare Medicare Appeals and Grievances Department P.O. Box 4010
Farmington, CT  06032-3124

Telephone:
800-224-2273

45 calendar days from receipt of remittance statement. 

Notification of determination is made within 30 days from receipt of the necessary information.

May file a facility clinical appeal.