Medicare claims, appeals, and inquiries
Submit a claim
eSolutions Help Desk
888-333-8594, Option 1
Monday through Thursday, 8 AM to 5 PM ET, and Friday, 8 AM to 4 PM ET
File an appeal
File an appeal when you are disputing the billing, coding, or medical necessity of a claim.
Filing an inquiry as an appeal, or vice versa, will cause delays.
For medical necessity reviews, complete the Medicare Advantage Provider Appeal Form (PDF) and file with supporting documentation.
For coding disputes, complete the Commercial and Medicare Provider Coding Disputes Form (PDF) and file with supporting documentation (required with submission effective 1/1/26).
Mail:
Blue Cross NC
Medicare Provider Appeals Department
PO Box 1291
Durham, NC 27702-1291
Fax:
- Billing and coding denials: 336-659-2947
- Medical necessity and administrative denials: 919-287-8815
Reach out to our appeals department for Blue Medicare HMO, PPO, and Healthy Blue + Medicare support.
888-296-9790 (toll-free)
Under the Centers for Medicare & Medicaid Services (CMS) regulations for Medicare Advantage plans, non-contract providers have the right to request reconsideration for a post service denial of payment by Blue Medicare HMO and Blue Medicare PPO if the payment was denied following an organization determination. Examples of organization determinations include services that were not prior approved and were determined not to be urgent/emergent; or services that were determined not covered either in the member's Evidence of Coverage or by Medicare. Other payment denials such as untimely filing, coding errors, filing errors, location errors, etc. are not considered organization determinations and are not appealable under Medicare regulations. Specific denial reasons and other claims information necessary to request the reconsideration will be listed on the provider's Explanation of Payment (EOP).
A non-contract physician or other non-contract provider must also formally agree to waive any right to payment from the enrollee for that service by completing a signed Waiver of Liability statement per CMS to file an appeal on his or her own behalf.
Non-contract post service provider appeals are available to physicians, physician groups, physician organizations, and facilities and are handled by Blue Cross NC.
Non-contact providers will have 60 calendar days from the date of the Explanation of Payment (EOP), notice of the organization determination, to submit a non-contracting post-service appeal. However, if the non-contract provider does not complete the Waiver of Liability statement within the appeal time frame, Blue Cross NC will forward the case to the Independent Review Entity (IRE), MAXIMUS with a request for dismissal.
This process is voluntary; however, a third party (such as a provider billing agency) cannot act on the provider's behalf in the appeal process.
For each step in this process, there are specified time frames for filing an appeal and for notification of the decision. Non-contract provider appeal reviews are completed within 60 calendar days of receipt of all information.
To begin the non-contract post-service provider appeal process, providers can download, print, and fill out the Provider Non-Contract Appeal Form (PDF) or mail in a written request and the Waiver of Liability Statement (PDF).
The provider may attach supporting documentation, such as a copy of the original claim, denial notice, and any clinical records, and mail it to the following address within the required time frame.
Blue Cross NC
Medicare Provider Appeals Department
PO Box 1291
Durham, NC 27702-1291
File an inquiry
File an inquiry when you have a contractual dispute that is not related to billing, coding, or medical necessity.
Filing an appeal as an inquiry, or vice versa, will cause delays.
Mail:
Blue Cross NC
Provider Inquiry Department
PO Box 2291
Durham, NC 27702-2291
Fax:
866-987-4167
Reach out to our inquiry department for Medicare support.
888-296-9790 (toll-free)