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Inquiry and Appeals Process


Provider Administrative Policy

Section
Information
Policy Date
May 2008
Status/Date
Revised/January 2010
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.

Policy

Inquiry and Appeals Process

Please follow the inquiry and appeal guidelines below for Blue Cross of Idaho claims processing issues. Providers must use these guidelines in conjunction with the terms of their provider contracts. Refer to your provider contract for time frames. The three levels of review for provider appeals on a denied claim are Inquiry, First-Level Appeal and Second-Level Appeal.

Inquiry – Blue Cross of Idaho will attempt resolution of provider-initiated inquiries through the course of normal operational interactions and our informal inquiry resolution process. Providers must initiate informal inquiries within the time frames stated in their provider contracts to protect subsequent rights for appeals. 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, email, fax or hard copy. Providers can initiate multiple inquiries on the same issue without escalating the issue to a formal appeal.

Blue Cross of Idaho defines an appeal as written correspondence regarding a claim issue previously reviewed through the inquiry process but still unresolved to the provider’s satisfaction or as a significant issue the provider chooses to submit immediately for a first-level appeal. All appeals must have a valid reason for consideration as stated in your provider contract. Valid reasons include, but are not limited to, issues regarding allowances, medical necessity and clinical editing.

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

Second-Level Appeal – If a provider is not satisfied with a first-level appeal determination, they may submit a second written appeal along with copies of any relevant supporting information to Blue Cross of Idaho’s provider appeals coordinator within the timeframe shown in their provider contract. A Second Level Appeal generally is referred for external review which carries a cost.

Documentation required for an appeal
Please provide the following documentation when appealing a claim:

  •  A letter summarizing what in the claim you disagree with and how you would like Blue Cross of Idaho to resolve the issue.
  • Provide supporting documentation from your specialty organization and/or local, state or nationally recognized organizations. If we based the denial on medical necessity, submit supporting 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 CMS 1500 or UB-04 form showing all procedure codes billed for the date of service
  • Blue Cross of Idaho’s inquiry and appeal form (requested under some contracts; required under others) 

    Inquiry and Appeal Form

    Blue Cross of Idaho returns appeals missing the above documentation or those submitted outside the timeframe specified in the provider’s contract. Please refer to your provider contract for specific appeal guidelines.

    Submit inquiries to:

    Blue Cross of Idaho
    Attn: Medicare Advantage Customer Service
    PO Box 8406
    Boise, Idaho 83707
    (Please mark envelope or email Confidential)

    Submit appeals to:

    Blue Cross of Idaho
    Attn: Provider Appeals Unit
    PO Box 7408
    Boise, Idaho 83707
    (Please mark envelope Confidential)

    Do not submit corrected claims to Blue Cross of Idaho`s provider appeals coordinator. Send corrected claims directly to the Blue Cross of Idaho claims department. Do not attach a cover letter to your corrected claim. Instead, indicate corrected claim on the claim form itself.

    Non-contracting providers submitting inquiries or appeals on claim denials must sign a Waiver of Liability form or have the patient sign an Appointment of Authorized Representative Form, in accordance with Medicare regulations, in order to have Blue Cross of Idaho consider their request.   Reconsideration requests from non-contracted providers must be received by Blue Cross of Idaho within sixty (60) days of the adverse determination.


Policy History

Date Action Reason
January 2010 Revised Language updated to reflect commercial provider administrative policy
October 2009 Revised Language change
July 2009 Revised Rewrite and title change
May 2008 Revised Language clarification

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