Understanding the medical appeals process
Why file an appeal?
An adverse benefit determination means a denial of coverage. This may happen if your health insurance:
- Has denied a benefit
- Won’t pay for a service you’ve already gotten
- Has canceled coverage
An Adverse Benefit Determination Letter, or denial letter, may be sent to you when a claim is denied. It includes details about:
- Why your claim was denied
- What information is needed to process an appeal
- How to file an appeal
Helpful appeals process information
You might file an appeal if your claim was denied for any of the following reasons:
- Your plan doesn't cover services or procedures listed on the claim or was denied due to a benefit limit.
- The procedures received are considered not medically necessary, experimental, investigational, or cosmetic.
- The coverage requires preauthorization.
Important Note: You must submit your appeal within 180 days of the date on the Adverse Benefit Determination or denial letter.
Use the Member Appeals Form (PDF) to file appeals. A Spanish language appeals form is available in our member forms library.
- Review the appeal instructions in your explanation of benefits (EOB), found in the Blue Cross NC member portal, or in your Adverse Benefit Determination Letter.
- Gather necessary information, including medical history, health records, referrals, or additional facts.
- Keep records of all claim documents and phone conversations, including dates, times, and notes taken.
- Complete the Member Appeal Representation Authorization Form (PDF) to choose a trusted representative to help with your appeals.
Make sure you include:
- Your name
- Your subscriber ID or member ID number (found on your member ID card)
- Service / claim information
- Reason for the appeal
- Any comments, supporting documents, records, and other information you'd like us to consider
Medical appeals forms can be submitted by US mail or by fax:
Mailing address:
Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
PO Box 30055
Durham, NC 27702-3055
Fax number:
919-765-4409
How long is the appeals process?
Blue Cross NC will review your appeal to determine whether the services you received are covered by your plan. Depending on your plan and the level of review your appeal requires, the timeline for deciding on your appeal may vary.
You can learn more about how long appeals may take by checking your Benefits Booklet in your member portal. You can also contact us for more information.
