Blue Medicare HMO Blue Medicare PPO

Level II Post-Service Provider Appeals

Level II Post-Service Provider Appeals for medical necessity or billing disputes are available to Physicians, Physician Groups, and Physician Organizations and will be performed by an Independent Review Organization, MES Solutions. Physicians, Physician Groups, or Physician Organizations must exhaust BCBSNC's Level I Post-Service Provider Appeal process before submitting a Level II Post-Service Provider Appeal. The Level I Post-Service Provider Appeal is deemed exhausted if BCBSNC does not communicate a decision within thirty (30) calendar days of BCBSNC's receipt of all documentation reasonably needed to make a determination on the Level I Post-Service Provider Appeal.

Level II Post-Service Provider Appeals administered by an Independent Review Organization, will be reviewed based on the information previously submitted with the Level I Post-Service Provider Appeal. There is a filing fee associated with all requests for a Level II Post-Service Provider Appeal.

Level II Post-Service Provider Appeal for Billing Disputes

The Level II Post-Service 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, or Physician Organizations must submit a written request for Level II Post-Service Provider billing dispute appeal within ninety (90) calendar days of the date of the Level I Post-Service Provider Appeal denial letter.

Level II Post-Service Provider Appeals should clearly identify the issue that is in dispute and rationale for the appeal. Demographic information including subscriber name, patient name, patient BCBSNC ID number, provider name, and provider ID number should also be included with any request for appeal. Level II Post-Service Provider Appeals require a filing fee to be submitted before the review can begin. 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 Street
Norwood, MA 02062

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

 

Level II Post-Service Provider Appeal 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, or Physician Organizations must submit a written request for a Level II Post-Service Provider Medical Necessity Appeal within sixty (60) calendar days of the date of the Level I Post-Service Provider Appeal denial letter. 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 Street
Norwood, MA 02062

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

Filing Fee Matrix

Billing Dispute

Amount of Dispute

Filing Fee Calculation

$1000 or less

Filing fee shall be equal to $50

Greater than $1000

Filing fee shall be equal to $250

Medical Necessity Dispute

Amount of Dispute

Filing Fee Calculation

$1000 or less

Filing fee shall be equal to $50

Greater than $1000

Filing fee shall be equal to $250

Note: 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 1 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.