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PAP236

Inquiry and Appeals Process


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/September 2011
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

To submit a reconsideration request on a denied pre-service prior authorization, refer to PAP241. That policy explains the prior authorization and the reconsideration process.

Effective January 1, 2010 claims for behavioral health services requiring prior authorization will be denied if prior authorization is not obtained and will not be eligible for a post service medical necessity review. All such behavioral health inquiries or appeals will be returned without further review.

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 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 how you would like Blue Cross of Idaho to resolve the issue.
  • 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 CMS1500 or UB-04 form that includes all procedure codes billed for that date of service.
  • Member and claim identification information including member name, member ID number, date of service and claim number if available.
  • Inquiry and appeal form (requested under some contracts; required under others) 

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 are submitting 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 right. If a provider wishes to appeal on behalf of the member, he may only do so with the member’s express permission. To appeal on behalf of our 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
September 2011 Revised Added bullet to "Documentation for Appeals" section.
April 2010 Revised Language clarification
October 2009 Revised Language clarification
July 2009 Revised Language updated to reflect contracts and form updated
August 2008 Revised Language clarification and form added

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