Understanding the appeals process

For most people, it’s to protect themselves from the unexpected. Whether it’s an unexpected hospital visit, broken bone, or stomach bug, we’ve come to plan for the unexpected. But what happens when your health insurance doesn’t cover something you expected it to or a doctor visit leads to a denied claim?

As a Blue Cross and Blue Shield of North Carolina (Blue Cross NC) member, you have the right to appeal a denied claim. But first, it’s important to know how to avoid a denied claim.

90% of claims submitted by our members are approved.

To avoid an unexpected denied claim, we recommend all members refer to their member booklet before receiving any medical service. Your member booklet is unique to your individual plan. These booklets may be available through Blue Connect. If you do not see this option, please contact your employer or customer service.

If you have any questions, call the number on the back of your health insurance card. A customer service representative can review your coverage with you. They can also identify additional options to help you make the best medical and financial decisions to fit your needs.

While the appeals process may be different because of regulations or plan details, all customers have an option to appeal their denied claims. You may also have an option of an external review by an independent physician. If you do not agree with the final decision, you may have the option to appeal with the North Carolina Department of insurance (DOI).

Don’t worry – we’re here to work with you and your doctor to make the appeals process go as smoothly as possible.

Below are the typical steps to move through the process.

As a health insurer, we must tell you why your claim or coverage was denied. Sometimes your claim was denied because of something simple like a wrong date of service, misspelled name or incorrect ID number. These problems can be corrected by your doctor. Then the claim can be resubmitted for reprocessing without an appeal.

If your claim was denied for one of the following reasons, an appeal may be required.

• Denial of services or procedures not covered by your policy
  
• Denial because a procedure is considered experimental, cosmetic, investigational or not medically necessary
  
• Denial because a referral or pre-authorization was required
  
• Denial because you used an out-of-network provider
  
• Denial due to policy limitation
  

Medical records, referrals, prescriptions from your doctor, and any relevant information about your medical history may help you get your claim approved.

Keep all your paperwork in one place. Take careful notes during every phone call with the insurance company or doctor’s office. Ask for the name of the person you’re speaking to and write down the date of the conversation and any next steps. Additionally, ask for a reference number for each call you make.

To submit an appeal for yourself, you can simply write a letter, but we have appeals forms available to help guide you through the process. If you are appealing on behalf of someone else, you will need to submit an authorization form.

These forms are available to our commercial (insurance through an employer), ASO (insurance through an employer who pays the claims but the insurer processes the claims) and individual commercial members (an individual who buys insurance themselves through an agent or the federal marketplace). All other plans can request the correct form from customer service.

Please submit your appeal form and necessary documentation in a timely manner. The timeline may vary depending on your plan. A customer service representative can provide you with the timeline for the process.

We want you to get the most out of your health insurance and for your voice to be heard. The appeals process is in place to give you and your doctor a chance to provide more information and open a dialogue. This way we can make sure you get the best care safely and at an appropriate cost. We understand that the unexpected happens and are committed to working with you when it does.