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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. These appeals may be submitted internally to Blue Cross NC without written consent from the member.
The pre-service review process is not changing. If a pre-service request is denied, providers may contact Healthcare Management and Operations (HCM & O) at 1-800-672-7897 for a pre-service Provider Courtesy Review (PCR). If the PCR is denied, the member can request a Level 1 pre-service appeal of the decision.
Providers may not appeal any issues that are considered member benefit or contractual issues. Examples of reviews not eligible for the provider to appeal on their own behalf are:
- Deductible/coinsurance issues
- Benefit limitations
- Benefit Exclusions
- Membership issues
If at any time a member and/or their authorized representative request an appeal during the review of a provider appeal, the member appeal takes precedence. At this time, the provider appeal will be closed.