Level II Post-Service Provider AppealsEffective November 21, 2008, Physicians, Physician Groups, and Physician Organizations may file a Level II Post-Service Provider Appeal for medical necessity or billing disputes. Level II Provider Appeals are conducted by an Independent Review Organization, and there is a filing fee associated with all requests for a Level II Post-Service Provider Appeal. Instructions for filing a Level II Post-Service Provider Appeal and a filing fee matrix are below. Level II Post-Service Provider Appeal for Billing Disputes: The BCBSNC Billing Dispute Resolution Process is available to resolve disputes over the application of coding and payment rules and methodologies to specific patients. Physicians, Physician Groups, and Physician Organizations must submit a written request for Level II Post-Service billing dispute Provider Appeal within ninety (90) calendar days of the date of the Level I Post-Service Provider Appeal denial letter. Physicians, Physician Groups, and Physician Organizations must exhaust BCBSNC's Level I Post-Service Provider Appeal process before submitting a review of a Level II Post-Service Provider Appeal. A Physician, Physician Group, or Physician Organization is deemed to have exhausted BCBSNC's Level I Post-Service Provider Appeal process if BCBSNC does not communicate a decision within thirty (30) calendar days of BCBSNC's receipt of all documentation reasonably needed to make a determination the Level I Post-Service Provider Appeal. To access our Pricing and Adjudication Principles for Professional Providers click here. If a Physician, Physician Group, or Physician Organization's Level I Post-Service Provider Appeal was completed by BCBSNC prior to November 21, 2008, and Level II Post-Service Provider Appeal rights are available, Physicians, Physician Groups, and Physician Organizations will have 90 days from November 21, 2008 to submit a Level II Post-Service Provider Appeal. Requests for Level II Post-Service Appeals may relate to the following types of issues:
Physicians, Physician Groups, or Physician Organizations should contact MES Solutions directly to submit a Level II Post-Service Provider Appeal for a Billing Dispute, or click here. Level II Post-Service Provider Appeal for Medical Necessity: Level II Post-Service Provider Appeals are available to Physicians, Physician Groups, and Physician Organizations to resolve disputes over the denial of investigational, experimental, cosmetic, and medical necessity determinations. Physicians, Physician Groups, and Physician Organizations must submit a written request for a Level II Post-Service medical necessity Provider Appeal within sixty (60) calendar days of the date of the Level I Post-Service Provider Appeal denial letter. Physicians, Physician Groups, and Physician Organizations must exhaust BCBSNC's Level I Post-Service Provider Appeal process before submitting a review for an external Level II Post-Service Provider Appeal. To access our Medical Policy click here If a Physician, Physician Group, or Physician Organization's Level I Post-Service Provider Appeal was completed by BCBSNC prior to November 21, 2008, and Level II Post-Service Provider Appeal rights are available, Physicians, Physician Groups, and Physician Organizations will have 90 days from November 21, 2008, to submit a Level II Post-Service Provider Appeal. Physicians, Physician Groups, or Physician Organizations should contact MES Solutions directly to submit a Level II Post-Service Provider Appeal for Medical Necessity or click here. Filing Fee Matrix:
Note: For Level II Post-Service Provider Appeals related to Billing Disputes, the disputed amount must exceed $500.00. In instances where the disputed amount is less than $500, the Physician, Physician Group, or Physician Organization may submit similar disputes to the Independent Review Organization within one (1) year of the original submission date. If the Physician, Physician Group, or Physician Organization intends to submit additional similar disputes during the year, the physician must contact the Billing Dispute Reviewer to notify that additional similar submissions will be sent. If the 1 year lapses and the disputes submitted are not in excess of $500 in the aggregate, the original dispute will be dismissed. |
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