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DPAP 205

Inquiry and Appeals Process


Provider Administrative Policy

Section
Information
Policy Date
January 2012
Status/Date
Revised/December 2012
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Blue Cross of Idaho works diligently on behalf of our members to develop contracting relationships with Idaho dental providers and Blue Cross Blue Shield dental affiliates (national Dental Grid).

 


Policy

Inquiry and Appeals Process

To submit a reconsideration request on a denied predetermination, refer to DPAP206. These policies explain the predetermination and the reconsideration process.

Follow the inquiry and appeal guidelines outlined below when issues arise after Blue Cross of Idaho processes the claim. You must use these guidelines in conjunction with your provider contract. Each contract contains the specific time frames for each activity.

Blue Cross of Idaho has three levels of review when providers appeal a denied claim: inquiry, first-level appeal and second-level appeal.

Inquiry - We will attempt to resolve provider-initiated inquiries through the course of normal operational interactions and Blue Cross of Idaho’s informal inquiry resolution process. Providers must initiate informal inquiries within the time frames stated in their provider agreements to protect subsequent rights for appeals. To clarify, we define provider inquiries as the first contact initiated by the provider to Blue Cross of Idaho. We recognize any form of inquiry, including telephone, e-mail, fax, or hard copy. Providers can initiate multiple inquiries on the same issue without escalating the issue to a formal appeal.

We define appeals as written provider correspondence about a claim issue, of which is the providers financial obligation (not member responsibility), previously reviewed through the inquiry process, yet still unresolved to the provider’s satisfaction, or, a weighty issue the provider chooses to immediately submit for first-level appeal. All appeals must have valid reasons for consideration as stated in your provider agreement. Appealable issues include, but are not limited to, allowances, medical necessity and clinical editing.

First-Level Appeal – If a provider is dissatisfied with a claims processing or administrative determination and has not found satisfactory resolution through the informal inquiry resolution process, the provider may submit a written appeal to Blue Cross of Idaho’s provider appeals coordinator within the time frame stated in the provider agreement.

Second-Level Appeal - If a provider is not satisfied with the first-level appeal determination, the provider may submit a second written appeal, and copies of any relevant supporting information, to Blue Cross of Idaho’s provider appeals coordinator. We must receive a second-level appeal within the time frame stated in the provider agreement.

Documentation for Appeals
Please include the following documentation when appealing a claim:

  • A letter summarizing what you disagree with and what you would like Blue Cross of Idaho to do.
  • Supporting documentation from your specialty organization and/or local, state, or nationally recognized organizations. If we based the denial on medical necessity, submit medical records and/or published evidence based on clinical trials or studies.
  • A copy of the operative report and/or office notes
  • A copy of the original American Dental Association (ADA) claim form that includes all procedure codes billed for that date of service

Inquiry and Appeal Form

If you do not attach all of the above documentation, or if you send your appeal outside the time frame specified in your provider contract, we will return your request without consideration. Please refer to your provider contract for specific appeal guidelines.

Submit all inquiries to:
Blue Cross of Idaho
Attn: Customer Service
PO Box 7408
Boise, Idaho 83707
(Please mark your envelope “
Confidential”)

Submit all appeals to:
Blue Cross of Idaho
Attn: Provider Appeals Unit
PO Box 7408
Boise, Idaho 83707
(Please mark your envelope “
Confidential.”)
(208)286-3559 
Fax

If you submit a corrected claim, please do not send it to the Provider Appeals Coordinator. Send corrected claims directly to the Claims Department. Please do not attach a cover letter to your corrected claim. Write "corrected claim" on the claim form.We will address all inquiries from both contracting and non-contracting providers. Non-contracting providers do not have a formal appeal.

If a provider wishes to appeal on behalf of the member (service denial as member liability), he or she may only do so with the member’s express permission. To appeal on behalf of a member, and exercise the member’s appeal rights, a member must complete and sign an Appointment of Authorized Representative Form appointing the provider as the representative. The Summary Plan Document outlines member appeal rights and processes. 


Policy History

Date Action Reason
December 2012 Revised Added American Dental Association and removed 2006 from claim form.