Reminder About Level I Provider Appeals
Providers participating in the Blue Cross and Blue Shield of North Carolina (BCBSNC) health care networks have the ability to request a post-service level I provider appeal, if they’re in question as to why a claim was denied or whether it was adjudicated correctly. A provider appeal is a formal review of a payment or denial about a processed claim, and it is performed for reasons related to our handling of codes and bundling, as well as to decisions of medical necessity for services.
Provider appeals for codes and bundling reasons are reviewed when services are bundled for being:
- An integral part of a primary service
- Mutually exclusive
- Not eligible for separate reimbursement
- Incidental to another service
- Surgical global included
Provider appeals for medical necessity decisions are performed when a member’s benefits are denied because:
- Medical necessity criteria was not met
- Services are considered cosmetic
- Services are considered investigational and/or experimental
- Pre-authorization for an inpatient hospital admission was not obtained
When requesting a specific claim decision to be reviewed through the provider appeals process for one (or more) of the above-listed reasons, please submit any supporting, objective medical documentation you may have that’s related to the request. Also, you can help control your (and our) administrative costs associated with sending us medical records by first verifying that the patient’s records document information that is consistent with BCBSNC medical policy, payment policy, and Claim Check clinical-edit rationale accessed through Blue eSM.
To request that a claim decision be reviewed through the provider appeal process, please contact us by one of the following methods:
- Call the Provider Blue LineSM at 1-800-214-4844.
- Contact the customer service number on the patient’s BCBSNC ID card, and they will forward appropriate issues to the BCBSNC Appeals Department for a provider appeal review.
- Complete the online level I provider appeal form, including objective medical documentation.
- Mail a letter of explanation, including any applicable objective medical documentation, to us at the following address:
Blue Cross and Blue Shield of North Carolina
Attn: Provider Appeals Unit
P.O. Box 2291
Durham, NC 27702-2291
- Fax inquiries to us at one of the following numbers:
- Provider billing/coding (bundling and fees): 919-287-8708
- Provider medical necessity: 919-287-8709
- State PPO: 919-765-2322
Level 1 provider appeal/reviews can be requested up to 90-calendar days from a specific claims’ adjudication date. All inquiries regarding the status of an appeal should be routed through customer service. Reviews are handled by BCBSNC within 45 days*, from the date of receipt of all necessary information, when the member’s coverage is through a BCBSNC commercially offered product. Reviews performed for services provided to BCBSNC’s Medicare Advantage members are conducted within 30 days of our receipt of the requestor-submitted, supporting objective medical documentation.
Information about our provider appeals process is available on our website at bcbsnc.com. For information about appealing a decision for payment of a specific member’s benefits, please contact us via the Provider Blue Line.
*Please note that in October 2012, BCBSNC extended the timeline for making level I appeal decisions from 30 days to 45 days, when conducting reviews of claims processed for members enrolled in BCBSNC’s commercial product lines. The online information for level I appeals was updated in October 2012 to reflect this change, and we are currently updating the Blue BookSM provider e-manual with the revised timeline, which will be available online for providers soon.