Level I Post-Service Provider Appeals

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Blue Medicare HMO

Blue Medicare PPO

Level I post-service provider appeals for billing/coding disputes and medical necessity determinations are available to physicians, physician groups, 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 for claims adjudicated on and after April 1, 2010.

These appeals are in addition to the non-contracting provider payment dispute process.

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. Level I Provider Appeal reviews are completed within 30 calendar days of the receipt of all information.

To begin the Level I post-service provider appeal process, download, print and fill out the Level I Provider Appeal Form.

Process for Billing and Coding Disputes

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

  • Coding/bundling or fee denials
  • Global Period Denial
  • Re-bundling
  • Services not eligible for separate reimbursement

Process for Medical Necessity

The Level I Provider Appeal Process for Medical Necessity applies to adjudicated claims related to:

  • Medical necessity determinations
  • Cosmetic services
  • Investigational/experimental services
  • No authorization for inpatient stay

Level I Provider Appeals for billing/coding disputes and medical necessity determinations should be submitted by sending a written request for appeals using the Level I Provider Appeal Form for Blue Medicare HMO and Blue Medicare PPO.

The provider may attach supporting medical information to the form and mail to the following address within the required time frame. Attaching supporting medical information is not required, but it will expedite handling of the appeal.

Blue Cross Blue Shield North Carolina
Provider Appeals Unit
Blue Medicare HMO and Blue Medicare PPO
PO Box 17509
Winston-Salem, NC 27116-7509

For more efficient delivery of your request, this information may also be faxed to the Provider Appeals Unit at (919) 287-8815.

This is the only level of appeal that is available to providers.

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