  Provider resources and informationAppeals processAn appeal is the member’s opportunity to request a redetermination of an adverse coverage determination, which includes denied exception requests. Example of an appeal:If the plan denies the member’s request for an exception to cover a non-formulary drug, then the member may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan. How do I file an appeal?If the member receives a coverage determination denial, the member or their appointed representative may file an appeal. A specific form is not required for the member to file an appeal. An appeal must be filed within 60 calendar days of the date of the denial notice and must be in writing, unless the member is filing an expedited or fast appeal. The member may submit it via:
When will I receive a decision on my appeal?The plan will perform a standard review of the member’s appeal as soon as their health requires but no later than seven (7) calendar days after the plan receives the member’s appeal. The plan will review requests for an expedited or fast appeal as soon as possible, but no later than 72 hours following their receipt of the request. An individual who was not involved with the member’s original coverage determination will make a decision on their appeal. The member will receive a written response to their appeal. The decision on an expedited appeal will be provided by phone followed by the written notice. If the plan’s decision is to deny the appeal, the notice will advise the member of their right to submit their appeal to the Independent Review Entity (IRE) with instructions on how to do so. If the plan misses its timeframes for claims adjudication or review of the appeal, the plan will automatically forward the appeal to the IRE for a decision. There may be additional levels of appeal available to the member. The plan will inform the member of their additional rights in the notice, or the member may refer to their Evidence of Coverage for further details. Appointing a representativeA Medicare beneficiary may appoint an individual to act as his/her representative in filing an appeal. A representative who is appointed by the court or who is acting in accordance with North Carolina law may also file an appeal. An appeal by a representative is not valid until the Appointment of Representative form below is completed and submitted, or other equivalent form, legal papers or authority are submitted.
Blue Cross and Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. |
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