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Knowledge Center

Understanding the appeals process

Was your claim denied when you think it should have been approved? Learn how to file an appeal.

Why file an appeal?

As a Blue Cross Blue Shield of North Carolina (Blue Cross NC) member, you have the option to file an appeal when a claim is denied. You may choose to file an appeal to dispute a payment, coverage decision, or for other adverse benefit determinations.

What is an adverse benefit determination?

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

What is an Adverse Benefit Determination Letter?

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

Helpful appeals process information

When 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.

How to get started on your appeal

Use the Member Appeals Form 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 to choose a trusted representative to help with your appeals.

What info to include on your appeal

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

Where to send your appeal

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:


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

How long is the appeals process?

Blue Cross NC will review your appeal to determine whether the services you received are covered by your plan. Depending on your plan and the level of review your appeal requires, the timeline for deciding on your appeal may vary. 

You can learn more about how long appeals may take by checking your Benefits Booklet in your Blue Connect member portal. You can also contact us for more information.