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Physicians, physician groups, and facilities may file a Level I Provider Appeal of Blue Cross NC's application of coding and payment rules to an adjudicated claim or of Blue Cross NC's medical necessity determination related to an adjudicated claim. These appeals include dissatisfaction with a claim denial for post-service issues that may be either provider or member liability.
Providers may not appeal any issues that are considered member benefit or contractual issues. These appeals are in addition to the non-contracting provider payment dispute process.
If at any time a member and/or their authorized representative request a post-service claim appeal during the review of a provider appeal, the member appeal takes precedence. At that time, the provider appeal will be closed.
Non-Contract Post-Service Provider Appeals
Under the Centers for Medicare & Medicaid Services (CMS) regulations for Medicare Advantage plans, non-contract providers have the right to request reconsideration for a post service denial of payment by Blue Medicare HMO and Blue Medicare PPO if the payment was denied following an organization determination. Examples of organization determinations include, services that were not prior approved and were determined not to be urgent/emergent; or services that were determined not covered either in the member's Evidence of Coverage or by Medicare. Other payment denials such as untimely filing, coding errors, filing errors, location errors, etc. are not considered organization determinations and are NOT appealable under Medicare regulations. Specific denial reasons and other claims information necessary to request the reconsideration will be listed on the provider's Explanation of Payment (EOP).
A non-contract physician or other non contract provider must also formally agree to waive any right to payment from the enrollee for that service by completing a signed Waiver of Liability statement per CMS to file an appeal on his or her own behalf.