An adverse benefit determination means a denial of coverage. This may happen if your health insurance:

• Has denied a benefit
• Won’t pay for a service you’ve already gotten
• Has canceled coverage

An Adverse Benefit Determination Letter, or denial letter, may be sent to you when a claim is denied. It includes details about:

• Why your claim was denied
• What information is needed to process an appeal
• How to file an appeal

You might file an appeal if your claim was denied for any of the following reasons:

• Your plan doesn't cover services or procedures listed on the claim or was denied due to a benefit limit.
• The procedures received are considered not medically necessary, experimental, investigational, or cosmetic.
• The coverage requires pre-authorization.

Important Note: You must submit your appeal within 180 days of the date on the Adverse Benefit Determination or denial letter.

Use the Member Appeals Form (PDF) to file appeals.

• Review the appeal instructions in your explanation of benefits (EOB), found in your Blue Connect℠ member portal, or in your Adverse Benefit Determination Letter.
• Gather necessary information, including medical history, health records, referrals, or additional facts.
• Keep records of all claim documents and phone conversations, including dates, times, and notes taken.
• Complete the Member Appeal Representation Authorization Form (PDF) to choose a trusted representative to help with your appeals.

Make sure you include:

• Your name
• Your subscriber ID or member ID number (found on your member ID card)
• Service / claim information
• Reason for the appeal
• Any comments, supporting documents, records, and other information you'd like us to consider

Appeals forms can be submitted by US mail or by fax:

Mailing address:

    Member Rights and Appeals
    Blue Cross and Blue Shield of North Carolina
    PO Box 30055
    Durham, NC 27702-3055

Fax number:

    919-765-4409

    State Health Plan PPO plan, fax forms to 919-765-2322