提供者上诉

Physicians, 医生组, and facilities may file a Level I Provider Appeal of Blue Cross NC's application of coding and payment rules to an adjudicated claim or of Blue Cross NC's medical necessity determination related to an adjudicated claim. These appeals include dissatisfaction with a claim denial for post-service issues that may be either provider or member liability. These appeals may be submitted internally to Blue Cross NC without written consent from the member.

The pre-service review process is not changing. If a pre-service request is denied, providers may contact Healthcare Management and Operations (HCM & O) at 1-800-672-7897 for a pre-service Provider Courtesy Review (PCR). If the PCR is denied, the member can request a Level 1 pre-service appeal of the decision.

Providers may not appeal any issues that are considered member benefit or contractual issues. Examples of reviews not eligible for the provider to appeal on their own behalf are:

• 免赔额/共同保险问题
• 利益的局限性
• 利益除外
• 会员的问题

If at any time a member and/or their authorized representative request an appeal during the review of a provider appeal, bat365官方下载上诉优先. At this time, the provider appeal will be closed.

Level I post-service provider appeals for billing/coding disputes and medical necessity determinations are available to physicians, 医生组, physician organizations and facilities and are handled by Blue Cross NC.

Providers have 90 calendar days from the claim adjudication date to submit a Level I Post Service Provider Appeal for billing/coding disputes and medical necessity determinations.

这个过程是自愿的. 这个过程中的每一步, there are specified time frames for filing an appeal and for notification of the decision. Level I Provider Appeal reviews are completed within 45 calendar days of the receipt of all information.

To begin the Level 1 Post Service Provider Appeal process, download, print and fill out the 一级提供者上诉表格.

账单/编码纠纷处理

The Level I Provider Appeal Process for billing/coding disputes applies to adjudicated claims related to:

• 基本服务的组成部分
• 互斥服务拒绝
• Services not eligible for separate reimbursement
• 偶然的过程否认
• 外科全球周期否认

医疗必要性流程

The Level I Provider Appeal 医疗必要性流程 applies to adjudicated claims related to:

• 医疗必要性决定
• 美容服务
• 临床实验/试验服务
• 没有住院许可

Level I 提供者上诉 for billing/coding disputes and medical necessity determinations should be submitted by sending a written request for appeal using the 一级提供者上诉表格 which is available online. With the form, the provider may attach supporting medical information and mail to the following address within the required time frame. Attaching supporting medical information will expedite the handling of the provider appeal.

北卡罗莱纳州的蓝十字和蓝盾
提供者上诉部门
P.O. Box 2291
达勒姆数控27702 - 2291

以便更有效地交付请求, this information may also be faxed to the Appeals Department using the appropriate fax number below. Faxing is the preferred method for providers to submit Level I appeals to Blue Cross NC.