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PAP236

Inquiry and Appeals Process


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/March 2015
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

Pre-Service Appeals - process to follow for prior authorization, hospital admission or concurrent review denials

Blue Cross of Idaho does not offer providers any appeal options for services, therapeutics or procedures excluded under the member contract.

Contracting providers have one level of pre-service appeal. Providers may submit a pre-service appeal to review a denial of a request for:  prior authorization, out of network services, admission to a hospital or a decision made by Blue Cross of Idaho during its concurrent review. We reserve the expedited appeal process for urgent care situations. Urgent care is any request for medical care or treatment with respect to which the application of the time period for making a non-urgent determination could result in the following circumstances:

  • Could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, based on a prudent layperson's judgement, or
  • In the opinion of a practitioner with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

We handle all other pre-service appeals as standard.

Standard - Must be submitted within 14 days of the original authorization denial. Blue Cross of Idaho will respond within 14 days of receiving the request.

Expedited - Must be submitted within 3 days of the original authorization denial. Blue Cross of Idaho will respond within 3 days of receiving the request.

Please submit all pre-service appeals with supporting clinical information via fax (208) 331-7344.

If a pre-service appeal is denied and the provider chooses to render the services anyway, the subsequent claim will be denied as not medically necessary and the provider will be held financially liable in the form of a contractual obligation on the remittance advice.

If the pre-service appeal is approved, the provider will be notified in writing that services have been authorized.

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.

For medical necessity reviews for non-authorized services please refer to PAP263.

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.

On-Line Post Service Claims Inquiry

Submit secure on-line inquiries for post-service claims on the secure provider portal on our website bcidaho.com, using one of the two options below:

Option 1

  1. Go to bcidaho.com/providers and log onto our secure website
  2. Select Eligibility and Claims
  3. Select Claims, search for the claim in question then select the claim to view the details
  4. If you have a question, select Provider Contact Center
  5. After typing your question, select Continue

With option 1, the form auto populates the appropriate member, provider and claim information. Simply type your question in the notes field. The system will securely deliver your submission following HIPAA compliancy guidelines.

Option 2

  1. Log onto our secure website, bcidaho.com
  2. Select Contact Us
  3. Select General Information under the Email heading
  4. Select a Question Category from the drop-down list. Select I have a different question, when unable to locate the claim on the website
  5. Complete the required fields marked with a red asterisk
  6. Select Submit Question

Post Service Informal Inquiries and Appeals

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 accept inquiries via 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 appeals to:

Blue Cross of Idaho
Attn:  Provider Appeals Unit
PO Box 7408
Boise, Idaho 83707
(Please mark you envelop "Confidential")
Fax:  208-286-3559

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 (PAP206).

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 a 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
March 2015 Revised Re-ordered customer service inquiries
January 2015 Revised Added section for pre service appeals
July 2014 Revised Added link to pap263
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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