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Providers

Blue Medicare HMO and Blue Medicare PPO appeals and inquiries

   

To ensure Blue Cross NC reviews your appeal or inquiry quickly, please review the instructions for completing the appeal form (PDF) and file appropriately. Submitting an inquiry as an appeal (or vice versa) will cause delays.

  • File an appeal when you are disputing the billing, coding or medical necessity of a claim.
  • File an inquiry when you have a contractual dispute that is not related to billing, coding or medical necessity.

File an appeal for Blue Medicare HMO and PPO claims

Instructions

  1. Within 90 days of claim adjudication date, complete and submit the level I provider Blue Medicare HMO and PPO appeal form.
  2. Mail completed appeal form and any supporting documentation to:

    Blue Cross NC
    Medicare Provider Appeals Department
    PO Box 1291
    Durham, NC 27702-1291

    Or fax to 919-287-8815
Provider Blue Medicare HMO/PPO appeal form (PDF)

Contact

Blue Medicare HMO and Blue Medicare PPO
888-296-9790 or
336-774-5400

Post-service appeals for non-contract providers

Under the Centers for Medicare & Medicaid Services (CMS) regulations for Medicare Advantage plans, non-contract providers have the right to request reconsideration for a post service denial of payment by Blue Medicare HMO and Blue Medicare PPO if the payment was denied following an organization determination. Examples of organization determinations include, services that were not prior approved and were determined not to be urgent/emergent; or services that were determined not covered either in the member's Evidence of Coverage or by Medicare. Other payment denials such as untimely filing, coding errors, filing errors, location errors, etc. are not considered organization determinations and are not appealable under Medicare regulations. Specific denial reasons and other claims information necessary to request the reconsideration will be listed on the provider's Explanation of Payment (EOP).

A non-contract physician or other non-contract provider must also formally agree to waive any right to payment from the enrollee for that service by completing a signed Waiver of Liability statement per CMS to file an appeal on his or her own behalf.

Non-contract post service provider appeals are available to physicians, physician groups, physician organizations and facilities and are handled by Blue Cross NC.

Non-contact providers will have 60 calendar days from the date of the Explanation of Payment (EOP), notice of the organization determination, to submit a non-contracting post-service appeal. However, if the non-contract provider does not complete the Waiver of Liability statement within the appeal time frame, Blue Cross NC will forward the case to the Independent Review Entity (IRE), MAXIMUS with a request for dismissal.

This process is voluntary; however, a third party (such as a provider billing agency) cannot act on the provider's behalf in the appeal process.

For each step in this process, there are specified time frames for filing an appeal and for notification of the decision. Non-contract provider appeal reviews are completed within 60 calendar days of receipt of all information.

To begin the non-contract post-service provider appeal process, providers can download, print and fill out the Provider Non-Contract Appeal Form (PDF) or mail in a written request and the Waiver of Liability Statement (PDF).

The provider may attach supporting documentation, such as a copy of the original claim, denial notice and any clinical records and mail to the following address within the required time frame.

Blue Cross NC
Medicare Provider Appeals Department
PO Box 1291
Durham, NC 27702-1291