Selectcare Case Summary

This category of claims involves the hospitals obtaining authorization for one procedure at a higher level of care, but then billing for a lower level of care. SelectCare denied the claims for a purported lack of authorization. However, in these claims, the procedure performed was substantially similar to the procedure that was authorized. Accordingly, no good faith basis existed for SelectCare to have denied the medically necessary services that were provided to its members.

Section 13.5 of the Agreement requires the parties to meet and confer in goof faith to resolve disputes arising under the Agreement. I therefore request that SelectCare contact me within thirty (30) days of its receipt of this letter to schedule a conference to