Provider Appeals

Level II Post-Service Provider Appeals

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.

This page includes instructions for filing a Level II Post-Service Provider Appeal and a filing fee matrix (see below for more details).

Appeals for Billing Disputes

Our 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 our 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 the Level I Post-Service Provider Appeal process if BCBSNC does not communicate a decision within forty-five (45) calendar days of BCBSNC's receipt of all documentation reasonably needed to make a determination the Level I Post-Service Provider Appeal.

Our Pricing and Adjudication Principles for Professional Providers includes more information about claims pricing and our adjudication processes.

Requests for Level II Post-Service Appeals may relate to the following types of issues:

  • An integral part of a primary service
  • Mutually exclusive services
  • Services not eligible for separate reimbursement
  • Incidental procedures denials
  • Surgical global period denials

Physicians, Physician Groups, or Physician Organizations should contact MES Solutions directly to submit a Level II Post-Service Provider Appeal for a Billing Dispute.

Mailing Address:
MES Solutions
100 Morse St
Norwood, MA 02062

Phone: 800-437-8583
Fax: 888-868-2087

Appeals 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 our Level I Post-Service Provider Appeal process before submitting a review for an external Level II Post-Service Provider Appeal.

Search our Medical Policy section for medical policy information.

Physicians, Physician Groups, or Physician Organizations should contact MES Solutions directly to submit a Level II Post-Service Provider Appeal for Medical Necessity.

Mailing Address:
MES Solutions
100 Morse St
Norwood, MA 02062

Phone: 800-437-8583
Fax: 888-868-2087

Filing Fee Matrix

Billing Dispute
Amount of Dispute Filing Fee Calculation
$1,000 or less Filing fee shall be equal to $50
Greater than $1,000 Filing fee shall be equal to $250
Medical Necessity Dispute
Amount of Dispute Filing Fee Calculation
$1,000 or less Filing fee shall be equal to $50
Greater than $1,000 Filing fee shall be equal to $250

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 one year lapses and the disputes submitted are not in excess of $500 in the aggregate, the original dispute will be dismissed.

The filing fee will be refunded in the event that the Physician, Physician Group, or Physician Organization prevails in the Level II post-service appeal process.