January 21, 2021
Starting February 1, 2021, Premera Blue Cross will require a signed member authorization for all appeals submitted on the member’s behalf. The member appeal form includes an authorization section for the member to sign and date. Providers will need to coordinate the submission of appeals with the member as the signed member appeal form must be included with any supporting documentation or medical records relevant to the appeal. The member appeal form is located in the forms section of our provider website.
This applies to member appeals for the following situations:
- Pre-service denial
- Request to reduce member financial responsibility
- Example: Requesting to waive member's cost shares
- Claim denial deemed the member’s responsibility to pay
- Example: Benefit is an exclusion, investigational, or experimental
Appeals regarding your contracted rates or provider payments aren’t member appeals and don’t require member authorization.
We understand the urgency and importance of getting appeals reviewed as quickly as possible. However, we must adhere to this process as required by the National Committee for Quality Assurance (NCQA).
Provider Appeal Forms
The provider appeal form has been updated to reflect submission of a level 1 or level 2 appeal. The complaint option has been removed as a level of appeal. This is because the provider appeal form is for submitting a dispute of one of our actions. If you have a non-appeal related concern you would like addressed, you can contact customer service.
Please use the updated forms when submitting appeals. Outdated forms marked as complaint submitted after February 1, 2021, will be handled as a level 1 appeal.