Non-Contract Post-Service Provider Appeals
Frequently Asked Questions (FAQs)
Frequently Asked Questions
A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the provider completes a Waiver of Liability statement, which states that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal. The appeal must be in writing.
***A third party vendor cannot file on behalf of the non-contract provider, the non-contract provider must file on his or her behalf***
The purpose of this statement is to ensure that the member will not be held financially liable if the provider loses the appeal. The signed Waiver of Liability document must be included in the appeal file submitted to BCBSNC. If it is not received within the appeal timeframe, BCBSNC will forward the appeal request on to the Independent Review Entity (IRE), MAXIMUS, Federal Services, Inc. for dismissal.
Waiver of Liability Statement
MAXIMUS, Federal Services, Inc. is the independent review entity that Medicare uses to review cases to make sure that the right decision was made.
If BCBSNC does not receive the form, BCBSNC cannot accept the appeal. Instead, the "case file" will be reviewed and submitted to MAXIMUS, Federal Services Inc., (IRE) for dismissal. However, the plan will make reasonable attempts to obtain the form in the appeal timeframe prior to sending to MAXIMUS.
Non-contact providers will have 60 calendar days from the date of the EOP, notice of the organization determination, to submit a Post-Service appeal. If the non-contracted provider does not complete the Waiver of Liability statement within the appeal time frame, BCBSNC will forward the case to the Independent Review Entity (IRE) with a request for dismissal.
Yes. The Medicare Advantage member appeal process as defined by Medicare is not changing.
It is not required by CMS for a non-contract provider to submit an appeal form. Non-contract providers should include the Waiver of Liability statement, documentation such as a copy of the original claim, denial notice, and any clinical records that support the appeal.
The appeal and/or forms can be mailed to:
Blue Medicare HMO (or PPO)
Attn: Non Contract Appeals and Grievances
P.O. Box 17509
Winston-Salem, NC 27116-7509.
Call 1-888-296-9790 and a BCBSNC representative can assist you.
Yes, but not with BCBSNC. If we uphold the denial we will forward the appeal on to MAXIMUS, Federal Services, Inc. (IRE) and notify the appellant of the appeal rights.