Gainwell Technologies, in collaboration with the Idaho Department of Health and Welfare, has revised the Claim Review Request (CRR) instructions and form. The updated and improved instructions and form can be found by hovering over the Reference Material tab and selecting Gainwell Technologies Forms or by following this link.
A Claim Review Request can be used for many reasons, but should not be used in some instances. Here are a few examples*:
|CRR is used:||CRR is not used:|
|If you disagree with the denial or payment of a claim and would like it manually reviewed||To adjust a claim and attach documentation (for example: EOB, invoice, sterilization/hysterectomy consent forms, NOA for timely filing, run/trip report) |
|If the claim has denied for a bundling issue against another denied claim/service line||For Share of Cost (SOC) issues |
|If the claim has denied for duplicate claim issues inappropriately ||To request additional information on a Health Management Systems (HMS) adjustment/recoupment|
|If a service was denied for a lifetime benefit exceeded inappropriately ||To request a recoupment when the claim is within the 2-year adjustment period |
|||To adjust a claim after a participant's eligibility has been updated|
*Note: This is not an all-encompassing list
All Claim Review Request forms must be mailed to Gainwell Technologies and the current form must be completed. Any CRR forms that are received via fax or email will not be processed into the system. If the form is incomplete it will be rejected and returned to the provider.
In the case where you may have more than five Claim Review Requests to send to Gainwell for reconsideration, you're encouraged to engage with your Provider Relations Consultant first; they can assist you with the denial and ensure using the CRR process is the most efficient way for your claim issues to be addressed.
When attaching documentation to the request do not attach the patient's entire medical record. For safety and efficiency in processing we ask that you only attach documents that are pertinent to the claim under review.
As of April 1, 2022 the updated form is expected to be used by providers and any Claim Review Request that is received on or after May 1, 2022 on the outdated form(s) will be returned to the provider.
Thank you for your cooperation and understanding for this necessary change!