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Level 1 Provider Appeal Form Required as of September 1, 2014

Blue Cross and Blue Shield of North Carolina (BCBSNC) offers providers the ability to request a retrospective review for processed claims, and/or a medical necessity determination we’ve made, if there is a question about the outcome. This request is a level 1 provider appeal, and the servicing provider can initiate the process without obtaining a member’s written authorization in advance.    

 

Level 1 provider appeals are available to providers when they want to request an additional review by BCBSNC for a claim that was denied or reduced in payment due to reasons such as code bundling; services considered cosmetic, investigational or experimental; or when a required preauthorization was not obtained. Providers have 90 calendar days from the date that BCBSNC processed a specific claim to submit a level 1 provider appeal for the claim in question.      

 

Please always download and use the Level 1 Provider Appeal form when submitting a level 1 provider appeal to BCBSNC. The form is available online in the Provider Appeals section of www.bcbsnc.com, and enables us to properly route your request, along with all supporting documentation, to the appropriate area for review. Although BCBSNC currently offers other options for submitting level 1 provider appeals, including provider-written cover letters or by contacting BCBSNC Customer Service, we will be discontinuing all other options for our commercial business as of September 1, 2014, in lieu of the more efficient online form.  

 

We recommend that you print a new form from the website each time you submit a level 1 provider appeal, in order to ensure that you are using the most current version. Please send the completed Level 1 Provider Appeal form to BCBSNC at the appropriate fax number listed below:

 

  • Review of a medical necessity denial, including no preauthorization for an inpatient stay: Fax to BCBSNC at (919)287-8709

 

  • Review of coding or bundling denials: Fax to BCBSNC at (919)287-8708

 

  • Review of State Health Plan PPO authorization denials: Fax to BCBSNC at (919)765-2322

 

Additional information about the level 1 provider appeal process can be found on our website at www.bcbsnc.com and in the Blue BookSM, BCBSNC’s online e-manual for providers. The e-manual will be updated with the information that the Level 1 Provider Appeal form will be the only accepted method for making a level 1 appeal request, beginning with reviews requested on or after September 1, 2014.

 

If you have any questions, please call the Provider Blue LineSM at 1.800.214.4844.