Provider Appeals FAQs
The right to appeal will be extended to providers for disputes of post-adjudicated claims related to medical necessity, billing/coding, and no preauthorization for an inpatient stay. Provider appeals may be submitted without written consent from the member, but must be submitted in writing from the provider.
Level I Provider Appeals for billing disputes, medical necessity denials, and denials for no preauthorization for an inpatient stay are handled by Blue Cross NC and available to all providers.
Yes. The member appeal process is not changing.
The member appeal will take precedence and the provider appeal will be closed. You will receive a letter notifying you that your case has been closed because the member has filed an appeal. Later, when a decision has been rendered, you will receive a copy of the member appeal decision letter.
In most cases, the Level I Provider Appeal is replacing the post-service Provider Courtesy Review. The only exception is that Provider Courtesy Reviews will be available for State PPO Pharmacy PA/QL (prior approval/quantity limit) denials.
The pre-service review process is not changing. If a pre-service request is denied, you can contact American Imaging Management (AIM), Member Health Partnership Operations (MHPO), or Value Options for a pre-service Provider Courtesy Review (PCR). If the PCR is denied, the member can request a Level I pre-service appeal of the decision. If the service is performed and the claim is denied, both the member and the provider have the right to request a post-service Level I appeal. If the service is performed and is denied as not medically necessary, the member and the provider both have appeal rights. If the service is performed and the claim denies for no prior review and charges are provider liability, neither the member nor the provider may appeal as this is a contractual denial.
No, there is no right for providers to appeal a denial for no prior review. These denials are considered administrative and are not eligible for review.
A new Appeals link has been added to the bluecrossnc.com provider website. You can also contact your Network Management representative.
Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Billing/Coding Dispute.
Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Medical Necessity Appeal.
A new form, the Level I Provider Appeal form, replaced the Provider Resolution Form. The Blue Book (also known as the "Provider Manual") has also been updated.
Because this form will continue to be updated from time to time, we recommended that you print the form from the website each time to ensure that you are using the most up-to-date version.
Access the form on the bluecrossnc.com provider website or through Blue e. Complete the form and fax it to one of the following numbers:
|Medical Necessity Denials (including no preauthorization for inpatient stay)||919-287-8709|
|State PPO Authorization Denials||919-765-2322|
Call 1-800-214-4844 and a Blue Cross NC representative can assist you.