Level I Appeals for Billing and Coding
Level I post-service provider appeals for billing/coding disputes and medical necessity determinations are available to physicians, physician groups, physician organizations and facilities and are handled by Blue Cross NC.
Providers have 90 calendar days from the claim adjudication date to submit the Level I Billing/Coding Dispute.
Providers have 90 calendar days from the claim adjudication date to submit the Level I Medical Necessity Provider Appeal.
The process is voluntary; however, a third party (such as a provider billing agency) can act on the provider's behalf in the appeal process.
For each step in this process, 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.
Process for Billing and Coding Disputes
The Level I Provider Appeal Process for billing/coding applies to adjudicated claims related to:
- An integral part of primary service
- Mutually exclusive services
- Services not eligible for separate reimbursement
- Incidental denials
- Surgical global denials
Process for Medical Necessity
The Level I Provider Appeal Process for Medical Necessity applies to adjudicated claims related to:
- Medical necessity determinations
- Cosmetic services
- Investigational/experimental services
- No authorization for inpatient stay
Level I Provider Appeals for billing/coding disputes and medical necessity determinations should be submitted by sending a written request for appeals using the Level I Provider Appeal form.
The provider may attach supporting medical information to the form and mail to the following address within the required time frame. Attaching supporting medical information is not required, but it will expedite handling of the appeal.
Blue Cross Blue Shield North Carolina
Provider Appeals - Level I
Network Support Department
PO Box 2291
Durham, NC 27702-2291
For more efficient delivery of your request, this information may also be faxed to the Appeals department using the appropriate fax number below. The form includes fax numbers and mailing addresses for submitting different types of appeals. Faxing is the preferred method for providers to submit Level 1 appeals to Blue Cross NC.
|Type of Appeal||Fax Number|
|Coding or Billing Denials||919-287-8708|
|Medical Necessity Denials: Cosmetic, investigational, experimental and no authorization for inpatient hospital admission||919-287-8709|
|State PPO Pharmacy Prior Authorization or Quantity Limit Denials||919-765-2322|
This is the only level of appeal that is available to providers.