Provider Appeals

Physicians, physician groups, 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:

• Deductible/coinsurance issues
• Benefit limitations
• Benefit Exclusions
• Membership issues

If at any time a member and/or their authorized representative request an appeal during the review of a provider appeal, the member appeal takes precedence. 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, 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.

This process is voluntary. 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 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 Level I Provider Appeal Form.

Process for Billing/Coding Disputes

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

• Integral part of primary service
• Mutually exclusive services denials
• Services not eligible for separate reimbursement
• Incidental procedure denials
• Surgical global period denials

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 appeal using the Level I Provider Appeal Form 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.

Blue Cross and Blue Shield of North Carolina
Provider Appeals Department
P.O. Box 2291
Durham, NC 27702-2291

For more efficient delivery of the request, 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.