Frequently Asked Questions
The right to appeal will be extended to providers for disputes of post-adjudicated claims related to medical necessity, billing/coding, and no preauthorization for an inpatient stay. Provider appeals may be submitted without written consent from the member, but must be submitted in writing from the provider.
Level I Provider Appeals for billing disputes, medical necessity denials, and denials for no preauthorization for an inpatient stay are handled by BCBSNC and available to all providers. Level I Provider Appeals and Provider Courtesy Reviews regarding mental health and substance abuse claims will be handled by Magellan.
Level II Provider Appeals for billing disputes and medical necessity denials are handled by an Independent Review Organization (IRO) and are available to physicians, physician groups, and physician organizations.
Yes. The member appeal process is not changing.
The member appeal will take precedence and the provider appeal will be closed. You will receive a letter notifying you that your case has been closed because the member has filed an appeal. Later, when a decision has been rendered, you will receive a copy of the member appeal decision letter.
In most cases, the Level I Provider Appeal is replacing the post-service Provider Courtesy Review. The only exception is that Provider Courtesy Reviews will be available for State PPO Pharmacy PA/QL (prior approval/quantity limit) denials.
The pre-service review process is not changing. If a pre-service request is denied, you can contact American Imaging Management (AIM), Magellan, Member Health Partnership Operations (MHPO), or Value Options for a pre-service Provider Courtesy Review (PCR). If the PCR is denied, the member can request a Level I pre-service appeal of the decision. If the service is performed and the claim is denied, both the member and the provider have the right to request a post-service Level I appeal. If the service is performed and is denied as not medically necessary, the member and the provider both have appeal rights. If the service is performed and the claim denies for no prior review and charges are provider liability, neither the member nor the provider may appeal as this is a contractual denial.
No, there is no right for providers to appeal a denial for no prior review. These denials are considered administrative and are not eligible for review.
A new Appeals link has been added to the bcbsnc.com provider website. You can also contact your Network Management representative.
Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Billing/Coding Dispute.
Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Medical Necessity Appeal.
A new form, the Level I Provider Appeal form, replaced the Provider Resolution Form. The Blue Book (also known as the "Provider Manual") has also been updated.
Because this form will continue to be updated from time to time, we recommended that you print the form from the website each time to ensure that you are using the most up-to-date version.
Access the form on the bcbsnc.com provider website or through Blue e. Complete the form and fax it to one of the following numbers:
|Medical Necessity Denials (including no preauthorization for inpatient stay)||919-287-8709|
|State PPO Authorization Denials||919-765-2322|
Call 1-800-214-4844 and a BCBSNC representative can assist you.
BCBSNC has decided to grant certain appeal rights to physicians only. BCBSNC made the decision to extend the right of the Level I to all providers and the Level II to physicians only.
If Level II Post-Service Provider Appeal rights are available, Physicians, Physician Groups, and Physician Organizations will have 90 calendar days from the date of the Level I Post-Service Provider Appeal denial letter to submit a Level II Post-Service Provider Appeal for a Billing Dispute.
If Level II Post-Service Provider Appeal rights are available, Physicians, Physician Groups, and Physician Organizations will have 60 calendar days from the date of the Level I Post-Service Provider Appeal denial letter to submit a Level II Post-Service Provider Appeal for Medical Necessity.
The filing fee structure is a provision of BCBSNC's provider appeal process. If BCBSNC's decision is overturned, the filing fee will be refunded to you. The grid below explains the fee structure for different types of appeals.
|Type of Dispute||Amount in Dispute||Filing Fee|
|Billing||$1,000 or less||$50|
|Greater than $1,000||$50|
|Medical Necessity||$1,000 or less||$50|
|Greater than $1,000||$250|
Contact MES Solutions directly:
Mail: MES Solutions
100 Morse Street
Norwood, MA 02062
Contact MES Solutions directly via the web, phone, fax or mail.
The Level II Provider Appeal requests for Billing Disputes administered by an Independent Review Organization, will be reviewed based on the information previously submitted with the Level I Provider Appeal. BCBSNC will supply all documentation from the Level I Provider Appeal to the Billing Dispute Reviewer. For additional questions, please contact MES Solutions directly.
Yes, the records should be submitted with the request to the external review vendor.