Frequently Asked Questions
The right to appeal is available 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 Post-Service Provider Appeals for claim denials related to billing/coding, cosmetic, experimental/investigational, medical necessity, and no preauthorization for inpatient stay are handled by BCBSNC and are available to all providers.
Level II Post-Service Provider Appeals for claim denials related to billing/coding, cosmetic, experimental/investigational, and medical necessity are handled by an Independent Review Organization (IRO) and are available to physicians, physician groups, and physician organizations.
Claim denials for no authorization for inpatient stay are eligible for a Level I Post-Service Provider Appeal but not a Level II Appeal.
Yes. The Medicare Advantage member appeal process as defined by Medicare is not changing. Providers can still appeal on behalf of the member in accordance with 42 CFR 422.578.
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.
You may access the Appeals link on 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 Post-Service Provider Appeal for any claims that are adjudicated on or after April 1, 2010.
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, it is 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. Complete the form and fax it to (919) 287-8815.
The Blue Medicare HMO and Blue Medicare PPO provider appeals form is also found in the Blue Book.
Call 1-888-296-9790 and a BCBSNC representative can assist you.
For billing disputes, when Level II Post-Service Provider Appeal rights are available, Physicians, Physician Groups, and Physician Organizations have 90 calendar days from the date of the Level I Post-Service Provider Appeal denial letter to submit a written Level II Post-Service Provider Appeal.
For medical necessity denials, when 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 written Level II Post-Service Provider Appeal.
The filing fee structure is a provision of BCBSNC. If BCBSNC's decision is overturned, the filing fee will be refunded. 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|