Changes to provider appeals forms for Commercial and Medicare business

Effective August 9, 2023, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will have the new and updated Commercial and Medicare appeals forms available on our website here. Providers are encouraged to start using the new forms on August 9, and the old forms will no longer be accepted after November 1, 2023. 

Level I provider appeals consist of retrospective reviews and do not require a member signed authorization. An appeal related to member benefits or contractual requirements/issues will not be reviewed and are not requests providers should submit as an appeal. The provider appeal process is separate from Blue Cross NC’s member rights and appeals process. If at any time the member files an appeal during a provider appeal review, the member’s appeal supersedes the provider appeal.  

Post-service provider appeals are performed based on a belief that a claim has been denied or adjudicated incorrectly. Post-service provider appeals for review of a processed claim may be submitted for the following reasons: 

• Coding/bundling, or fees  

• Cosmetic  

• Experimental/investigational  

• Global period denial  

• No authorization for inpatient admission  

• Non-contracted provider payment dispute  

• Not medical necessary  

• Re-bundling  

• Services not eligible for separate reimbursement 

All appeals are required to be submitted within 90 days of the date of the denial.  

Level I post-service provider appeals are handled within forty-five (45) days from the date of receipt of all information. Supporting objective medical documentation should be submitted for post-service provider appeal reviews. 

The revised appeal forms for Medicare Advantage/Blue Medicare and commercial business are here along with instructions.