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Denial & Claim Guidance

Filing claims properly is an important part of the reimbursement process. If you have a disagreement on a claim payment, need to correct a claim, or need more information on why a claim was denied, please read through the processes below.

Prior Authorization Denials

  • Providers must work with members to utilize the member appeal process for this type of denial. Appeals on behalf of the member must have written authorization from the member. More about the member appeal process is below.
  • Appeal must be submitted on the OHP 3302 form which is included with the NOABD or at the link below.

Claim Denials

Claim Denied for No Prior Authorization, Non-Covered Diagnosis or Service, & Other Denials Resulting in an NOABD (Denial Notice):

  • Providers must work with members to utilize the member appeal process for these types of denials. Appeals on behalf of the member must have written authorization from the member. More about the member appeal process is below.
  • Appeal must be submitted on the OHP 3302 form which is included with the NOABD or at the link below.

Timely Filing

  • If due to a system issue (submitted electronically and there is documentation of the submission) contact the Claims Department. Providers can use the reconsideration form and supporting documentation these should be sent directly to Claims: Fax: (503) 315-4135 or Email: yamhillclaims@ayin.com
  • EOB Related: Documentation can be attached to the claim in CIM *You MUST email yamhillclaims@ayin.com through the claim in order to alert claims to the attachment.*
  • If the claims department upholds your timely filing denial you can then fill out a provider reconsideration timely filing denial form (reach out to YCCO Provider Appeals to request this form – the claims department may also provide one with their decision) and attach all documentation from the claim department reviews with your supporting documentation pertaining to your request. A provider reconsideration will not be accepted prior to a claim department review. This request must be submitted within 60 days from the date of the denial.

Pricing

Disagreement on claim payment.

Corrected Claim

Claim has an error or needs corrected.

  • Contact Claims Department or resubmit a corrected claim.

Claims Denied for Chartnotes Not Submitted

Chartnotes needs to be added to the claim or sent to the Claims Department.

  • Add your required chartnotes to the claim via CIM.
  • Send your chartnotes to the Claims Department (include the claim number, member name, member ID with your request)

Fax: (503) 315-4135

Email: yamhillclaims@ayin.com

Submitting an Appeal on Behalf of a Member

The member appeal form is located here:

OHP 3302 Appeal and Hearing Request (PDF)

Member appeals must be submitted within 60 days from the date of the denial. Providers must have written authorization from the member to appeal on their behalf.

You can mail, fax or email your appeal:

  • Fax: 503-765-9675
  • Email: appeals@yamhillcco.org
  • Mail: Yamhill Community Care
    • Attn: Appeals & Grievance Specialist
    • PO Box 5490
    • Salem, OR 97304
  • Phone: 971.345.5933, please use the provider prompt

Members have the right to appeal denials and receive a form (OHP 3302) included with the YCCO denial letter. Member appeals must be submitted within 60 days from the date of their NOABD (denial letter). The member, their representative, or provider with member’s written consent may file an appeal orally or in writing. More information on the member appeal process can be found in the Provider handbook or Member handbook (PDF).