提供者上诉

医生, 医生组, and facilities may file a Level I Provider Appeal of 蓝十字数控's application of coding and payment rules to an adjudicated claim or of 蓝十字数控'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 蓝十字数控 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) 1- 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.

供应商 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:

  • 免赔额/共同保险问题
  • 利益的局限性
  • 利益除外
  • 会员的问题

If at any time a member and/or their authorized representative request an appeal during the review of a provider appeal, 会员上诉优先. At this time, the provider appeal will be closed.

Level I post-service provider appeals for billing/coding disputes and medical necessity determinations are available to physicians, 医生组, physician organizations and facilities and are handled by 蓝十字数控.

供应商 have 90 calendar days from the claim adjudication date to submit a Level I Post Service Provider Appeal for billing/coding disputes and medical necessity determinations.

这个过程是自愿的. 对于这个过程中的每一步, there are specified time frames for filing an appeal and for notification of the decision. Level I Provider Appeal reviews are completed within 45 calendar days of the receipt of all information.

To begin the Level 1 Post Service Provider Appeal process, download, print and fill out the 一级供应商申诉表格.

计费/编码纠纷处理

The Level I Provider Appeal Process for billing/coding disputes applies to adjudicated claims related to:

  • 主要服务的组成部分
  • 拒绝互斥服务
  • Services not eligible for separate reimbursement
  • 偶然的过程否认
  • 手术全球期否认

医疗必需品处理程序

The Level I Provider Appeal 医疗必需品处理程序 applies to adjudicated claims related to:

  • 医疗必要性决定
  • 美容服务
  • 临床实验/试验服务
  • 没有住院许可

Level I 提供者上诉 for billing/coding disputes and medical necessity determinations should be submitted by sending a written request for appeal using the 一级供应商申诉表格 which is available online. 与形式, the provider may attach supporting medical information and mail to the following address within the required time frame. Attaching supporting medical information will expedite the handling of the provider appeal.

北卡罗来纳州的蓝十字和蓝盾
提供者上诉部门
P.O. 2291箱
达勒姆数控27702 - 2291

以便更有效地交付请求, this information may also be faxed to the 上诉 Department using the appropriate fax number below. Faxing is the preferred method for providers to submit Level I appeals to 蓝十字数控.

类型的吸引力 传真号码
编码否认
医学必要否认:
  • 化妆品
  • 临床实验/试验
  • 无住院许可

This is the only level of appeal that is available to providers.

For assistance completing the provider appeal form, please use the following 服务提供者上诉须知.