When to submit an appeal |
When not to submit an appeal |
- Clinical edit disagreement – with the appeal, submit supporting documentation (such as CMS) showing correct billing
- Medical necessity denials that are provider write-offs
- If allowed amounts disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials
- Claims denied for timely filing
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- Billing errors
- Duplicate or eligibility denials
- Corrected claims
- Claims denied for needing medical records, incident questionnaires, or other additional processing info
- Other coverage denials like COB, worker’s comp or subrogation
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Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers.
Appeals
Appeal submission with authorization - Resolve billing issues that directly impact payment or a write-off amount. Note the different fax numbers for clinical vs. general
appeals. Member authorization is embedded in the form for providers submitting on a member’s behalf (section C).
BlueCard appeal submission - For out-of-area BlueCard members appealing the home Blue plan.
View our individual plans page for additional appeal forms.
Policy reconsideration
Policy reconsideration - Request reconsideration of a coding policy.