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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.
CLICK HERE for an overview of the complete Reconsideration Process
Expedited Reconsideration
Is available for denials rendered by a physician reviewer during admission or concurrent reviews, and requested while the patient is still hospitalized. 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.
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.
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.
Providers may use the following eQHealth forms as their written response:
Reconsideration Request Form and Instructions
DRG Reassessment Form
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Request for Reconsideration or Reassessment
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Submission Requirements
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Fax or mail your request:
Fax: 800-418-4039
Mail: eQHealth Solutions
Attn: Reconsideration
2050-10 Finley Road
Lombard, IL 60148
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The hospital or physician may submit a request, in writing, within 60 calendar days from the date of denial notice or the DRG change notice:
Note: To initiate peer-to-peer contact: Provide written request and contact information as part of the request for reconsideration or reassessment.
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