Provider Appeals

Level I post-service provider appeals are handled by BCBSNC and are available to physicians, physician groups, physician organizations and facilities.

Providers will have 180 calendar days from the claim adjudication date to submit a Level I Billing/Coding Dispute for any claim related to Post-Service Billing/Coding Disputes that were adjudicated prior to August 21, 2008. If the claim adjudication date is August 21, 2008, or after, the provider will have 90 calendar days to submit the Level I Billing/Coding Dispute.

Providers will have 180 calendar days from the claim adjudication date to submit a Level I Medical Necessity Appeal for any claim related to Post-Service Medical Necessity that was adjudicated prior to September 15, 2008. If the claim adjudication date is September 15, 2008, or after, the provider will have 90 calendar days from the adjudication date to submit the Level I Medical Necessity Provider Appeal.

This process is voluntary; however, a third party (such as a provider billing agency) cannot 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 will be completed within 30 calendar days of the receipt of all information.

Provider Appeal Process for Billing/Coding Disputes

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

• Integral part of primary service
• Mutually exclusive services
• Services not eligible for separate reimbursement
• Incidental denials
• Surgical global denials

Provider Appeal 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

The provider may pursue a post-service Level I Provider Appeal for billing/coding disputes and medical necessity determinations by sending a written request for appeals using the Level I Provider Appeal form. With the form, the provider may attach supporting medical information and mail to the following address within the required time frame. Attaching supporting medical information is not required. However, it will expedite the 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 BCBSNC.