Wiki BCBS Appeal Process

[RebeccaWoodward*]

I have a surgical claim that denied for lack of medical necessity. The claim was appealed with a provider resolution form. It was submitted by our billing department with hopes to overturn the denial. Without going into details of the appeal itselt, it was not successful. Now...here's the kicker! BCBS now requires that all level II appeals go through an outside agency. For claims that denied for lack of medical necessity and over a $1000, they request a fee of $250 to reconsider the claim. I was appalled when I heard this. BCBS implemented this policy 11-21-08. Does your BCBS carrier do this???

 

[okiesawyers]

WOW~~ I had not heard of that one yet! That's awful!! Anyone else heard of this?

 

[mbort]

I have a surgical claim that denied for lack of medical necessity. The claim was appealed with a provider resolution form. It was submitted by our billing department with hopes to overturn the denial. Without going into details of the appeal itselt, it was not successful. Now...here's the kicker! BCBS now requires that all level II appeals go through an outside agency. For claims that denied for lack of medical necessity and over a $1000, they request a fee of $250 to reconsider the claim. I was appalled when I heard this. BCBS implemented this policy 9-15-2008. Does your BCBS carrier do this???

NO WAYYYYYYYYYYYYY!!! ughhhhhhhhhhhhhhhhhh that utter nonsense!! Can they legally do that?? It just doesnt seem right. Have you called your provider rep to verify this?

 

[RebeccaWoodward*]

http://www.bcbsnc.com/content/providers/appeals/LevelIIProviderAppeals.htm

However..."The filing fee will be refunded in the event that the Physician, Physician Group, or Physician Organization prevails in the Level II post-service appeal process."

I don't know about you guys but our BCBS carrier is horrible when it comes to overturning a denial.

 

[Lisa Bledsoe]

BCBS is horrible period. We have to meet with our provider reps weekly just to simply get claims paid!

 

[k-jag]

That's horrible!!!! Does your patient know what is going on? If not, tell them, and see if you can get them to lodge a member complaint.

Does your state have an insurance commissioner or some kind of department of insurance like California does to investigate these issues? If not, try contacting your state medical association to see if they are working on this.

Good luck,

 

[RebeccaWoodward*]

I am definitely going to check it out. Someone recommend bypassing this policy and continue to submit the appeals (any level) directly to BCBS. It's worth a try but I can see it now...request denied. What a way to start off my week!

 

[Mjones7]

This is super unbelievable!!!! Does your contract not stipulate an arbitration period? I am not fond of BCBS and have had the pleasure of beating them in court a few years back while working for a surgery center. I certainly wish you well but I would review the provider contract first before surrendering $250 bucks....BEST WISHES.

 

[rthames052006]

never had issues like this before

Fortunately on my side I've never had any real serious issues with our BCBS carrier. My rep is wonderful, no matter how silly my question may be she is always very responsive and will resolve issues in a timely manner.

Sorry to hear your having issues....

I am considering asking my rep if she is "aware" of this issue your having just to see what kind of an answer I get.

 

[jthweatt]

Same for our BCBS carrier (Alabama). Once the internal appeals process is exhausted it is a $50 fee if under $1000 in question and $250 if over $1000.

Jerri, CPC