Provider Complaints, Disputes, and Appeals

A provider complaint is any expression by any provider indicating dissatisfaction with an AmeriHealth Caritas Louisiana policy, procedure, or any other aspect of administrative functions (excluding requests for reconsideration of a claim or prior authorization denials/reductions) filed by phone, in writing, or in person with AmeriHealth Caritas Louisiana.

Examples of complaints

Examples of provider complaints include:

  • Claims processing issues, such as lack of timely payment.
  • Dissatisfaction with AmeriHealth Caritas Louisiana's prior authorization process or turnaround times.
  • Primary care provider (PCP) linkage concerns, including PCP auto-assignment methodology and patient linkage policies, procedures or results.
  • Provider enrollment or credentialing issues, such as lack of timely processing or allegation of a discriminatory practice or policy.
  • Lack of access to providers or services, such as difficulty in locating specialty providers that will agree to treat members.
  • Provider directory or database issues, including incorrect information or lack of information in AmeriHealth Caritas Louisiana's system and/or directory.
  • Lack of information or response, including failure by AmeriHealth Caritas Louisiana to return a provider's calls, infrequency of site visits by AmeriHealth Caritas Louisiana's Provider Network Management account executives, or lack of provider network orientation/education by AmeriHealth Caritas Louisiana.

How to file a complaint

  • By phone:
    Call Provider Services at 1-888-922-0007 from 7 a.m. to 6 p.m. Central Time, Monday through Friday.
  • By mail:
    Attn: Provider Complaints
    AmeriHealth Caritas Louisiana  
    P.O. Box 7323
    London, KY 40742
  • By email:
    Network@amerihealthcaritasla.com
  • By online portal in NaviNet.
  • You may also request an on-site meeting to discuss your complaint. You may file a complaint with your Provider Network Management account executive.

Claim dispute process

A claim dispute is a request for post-service review of claims that have been previously denied, underpaid, or otherwise limited claim by AmeriHealth Caritas Louisiana.

How to file a claim dispute

You may file a claim dispute by submitting a completed Provider Claim Dispute Form (PDF), which can be found in the provider forms section or you may submit through the online portal in NaviNet.

Mail your completed form to:

AmeriHealth Caritas Louisiana  
Attn: Provider Disputes
P.O. Box 7323
London, KY 40742

Claim disputes should be marked “first-level" or "second-level" claim dispute on the outer envelope and in the correspondence.

  • First-level claim dispute: an initial written request for post-service review of claims.
  • Second-level claim dispute: a secondary written request for review of first-level claim dispute resolution.

Multiple claims with different denial reasons should not be submitted on the same form.

If several claims are impacted by the same issue, you may submit the claim dispute via the multiple claims project spreadsheet (PDF).

Claim dispute time frames

Claim disputes are acknowledged by AmeriHealth Caritas Louisiana within three business days. 

First-level claim disputes

First-level claim dispute requests must be received within 180 calendar days of the remittance advice or denial. A determination will be made within 30 calendar days of receipt of the claim dispute by AmeriHealth Caritas Louisiana.

Second-level claim disputes

If you are dissatisfied with the first-level claim dispute resolution, you may file a second-level claim dispute within 30 calendar days of the date on the first-level claim dispute determination letter.

Second-level claim disputes will be reviewed and decided upon by second-level claim dispute reviewers of AmeriHealth Caritas Louisiana leadership or their designees.

A determination will be made within 30 calendar days of receipt of the claim dispute by AmeriHealth Caritas Louisiana.

Independent review process

Step 1: Request for claim reconsideration

Claim reconsideration allows providers dissatisfied with an adverse claim determination to request additional review by their managed care organization (MCO).

  • Must be submitted in writing on the Louisiana Department of Health (LDH)-required form within 180 days of one of the following:
    • The transmittal date of an electronic remittance advice (ERA) or the postmark date of a paper ERA.
    • 60 days from the claim submission date if no ERA is received.
    • The date of claim recoupment.
  • Can be mailed to:
    AmeriHealth Caritas Louisiana
    Attn: Provider Disputes
    P.O. Box 7323
    London, KY 40742.
  • Or emailed to: ACLAIndependentReviewRequest@amerihealthcaritas.com.
  • Or submitted in the online portal in NaviNet.
  • Providers may initiate a reconsideration using the Independent Review Provider Reconsideration form PDF).
  • Will be resolved by AmeriHealth Caritas Louisiana within 45 days of receipt.

Step 2: Request for independent review

If a provider is still not satisfied with the determination after the claim reconsideration process by the MCO, the provider may submit a request for independent review. 

  • Must be submitted in writing on the LDH-required form within 60 days of one of the following:
    • The date of the MCO’s reconsideration decision.
    • The last day of the MCO’s 45-day time period to enter a reconsideration decision, if no decision is received.

Must be mailed to:

Louisiana Department of Health
Attn: Health Plan Management
P.O. Box 91030, Bin 24
Baton Rouge, LA 70821-9283.

Arbitration

If you are not satisfied with AmeriHealth Caritas Louisiana's internal claim dispute resolution, you have the option to request binding arbitration by a private, independent arbitrator who is certified by a nationally recognized association that provides training and certification in alternative dispute resolution. Arbitration requests must be submitted in writing to AmeriHealth Caritas Louisiana within 30 days of the second-level dispute determination letter to:

AmeriHealth Caritas Louisiana
Market President
Attn: Arbitration
10000 Perkins Rowe
Block G, 4th Floor
Baton Rouge, LA 70810

Arbitration regarding a claim dispute is binding on all parties. The arbitrator will conduct a hearing and issue a final ruling within 90 calendar days of being selected, unless you and AmeriHealth Caritas Louisiana mutually agree to extend this deadline. All costs of arbitration, not including attorney's fees, are shared equally by the parties. You must exhaust AmeriHealth Caritas Louisiana's internal claim dispute process before proceeding to arbitration. You do not have the right to a state fair hearing for claim issues.

Providers