Administrative appeals are the process by which claims denials that are not approved because they do not meet contractual or administrative requirements are reviewed. Administrative denials are not denied based on medical necessity guidelines.
Administrative appeals requests
- This process is based on the PerformCare policy QI-041 Appeals of Administrative Denials (PDF).
- The Administrative Appeal Request form (PDF) must be completed and included with every submission, or the appeal may be rejected for insufficient information.
- Before submitting an administrative appeal request to PerformCare, the provider must have billed a claim and received a claims denial notification.
- An administrative appeal will not be processed without a specified claim number(s) included on the Administrative Appeal Request form (PDF).
- Please submit all administrative appeal requests by mail to:
PerformCare Administrative Appeals
P.O. Box 7301
London, KY 40742
- Please use the Multiple Administrative Appeals spreadsheet (XLS) when your appeal has 10 or more claims. Email the completed form back to your Account Executive.
- Appeal decisions are made within 30 days of receipt by PerformCare.
- The process allows only a one-time submission. PerformCare does not offer second-level appeals. Therefore, please include completed information and all appropriate supporting documentation with the first submission. All decisions are final.
- For assistance, call PerformCare’s Claims department at 1-888-700-7370, option 1.
- Review complete details of the administrative appeals process and FAQs (PDF).
What information should be included with the administrative appeal request?
For requests related to retroactive eligibility issues:
- If an appeal is related to an eligibility issue, always include eligibility verification system (EVS) documentation from the start date of service with your appeal request.
- If appeal is related to substance abuse services, please include documentation of the member's American Society of Addiction Medicine (ASAM) criteria.
- If appeal is related to a service that requires precertification for authorization, please include the member's medical record.
- If the appeal is related to behavioral health rehabilitation services (BHRS), please submit the member's complete BHRS request packet.
- If the appeal is related to family-based mental health services (FBMHS), please include all progress notes for one month before the dates of service and specify the exact number of additional units requested for each date of service.
For requests involving services that require pre-authorization:
- Member's medical records or progress notes must be submitted.
- Medical necessity criteria must be met.
- Authorization from the primary insurer must be included (if applicable).
For requests related to primary claims denials:
- Explanations of benefits (EOBs) or denial letters from the primary insurer must be included.
- Appeal request must be submitted within 60 days of the date on the primary insurer's EOB/denial letter.