Providers have the right to file a dispute regarding the Managed Care Plan’s policies, procedures, or any aspect of a Managed Care Plan’s administrative functions, including proposed actions, claims/billing disputes, and service authorizations. 


Providers do not have appeal rights through the enrollee plan appeals process. 

How do Providers File a Complaint? 

1. Non-Claim issues, Lighthouse shall: 
    a) Allow providers forty-five (45) days to file a written Complaint.
    b) Within three (3) business days of receipt of a Complaint, notify the provider (verbally or in writing) that the Complaint has been received and the expected date of resolution; 
    c) Thoroughly investigate each provider Complaint using applicable statutory regulatory, contractual, and provider agreement provisions; collect all pertinent facts from all parties; and apply applicable plan written procedures; 
    d) Provide written notice of the status to the provider every fifteen (15) days thereafter; and 
    e) Resolve all Complaints within ninety (90) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution. Lighthouse shall maintain a complete and accurate record of all Complaints and shall make such records available upon request of the Agency. 

2. Claim issues, in accordance with 641.3155 Florida Statutes, Lighthouse shall: 
    a) Allow providers ninety days (90) from the date of the final determination for the primary payer to file a written Complaint for claims issues; 
    b) Within three (3) business days of receipt of a claim Complaint, notify the provider (verbally or in writing) that the Complaint has been received and the expected date of resolution; 
    c) Within fifteen (15) days of receipt of a claim Complaint, provide written notice of the status of the Complaint to the Agency and to the provider. For claims issues that require additional time to research, Lighthouse must submit a written request to the Agency within three (3) business days of receipt of the Complaint that includes: 
    i. An explanation for the need of an extension; and 
    ii. The expected time needed beyond the fifteen (15) days for research and response. 
    iii. Approval is contingent upon Agency review. 
    iv. Lighthouse must provide written notice of the status to the provider every fifteen (15) days thereafter; and 

(d) In accordance with 641.3155, F.S., resolve all claims Complaints within sixty (60) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution. 
Providers must return any overpayment to Lighthouse at the address set forth in this handbook within sixty (60) days after the date on which the overpayment was identified, as well as notify Lighthouse in writing of the reason for the overpayment. (42 CFR 438.608 (d)(2)). 
 

Submit Provider Complaints to: 

Type of Appeal

Timing of Appeal

Address

Claims Payment Issues

Must be submitted within ninety (90) calendar days of last process date of claim.

Lighthouse Health Plan

PO BOX 211126

Eagan, MN 55121

Non-Claims Issues

Must be submitted within forty-five (45) calendar days of last process date of claim.

Lighthouse Health Plan

PO BOX 211126

Eagan, MN 55121

Contractual Issues

Must be submitted within ninety (90) calendar days of the occurrence of the contractual issue being appealed.

Lighthouse Health Plan

PO BOX 211126

Eagan, MN 55121

Credentialing Denial or Credentialing or Quality Network Termination

Must be submitted within thirty (30) calendar days of the adverse benefit determination. Provider may request a hearing.

Lighthouse Health Plan

PO BOX 211126

Eagan, MN 55121

Overpayment Recovery and Recoupment

Must be submitted within 60 calendar days from postmark date or electronic delivery date of written notice of overpayment recovery request.

Lighthouse Health Plan

PO BOX 211126

Eagan, MN 55121