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Welcome
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 * Home
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 * Claims and Eligibility
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 * Pharmacy Program
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   Equivalent Exclusion Prior Authorization and Step Therapy Specialty Pharmacy
 * Standards and Requirements
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   Medical Policy Medical Policy/Pre-cert (Out-of-area) Medicare Advantage PFFS
   Risk Adjustment




 * Claims and Eligibility
 * Electronic Commerce
 * Eligibility and Benefits
 * Utilization Management
 * Pre-cert Router (out-of-area)
 * Claim Submission
 * Claim Status and Adjudication
 * Claim Payment and Remittance
 * Claim Review and Appeal
 * Refund Management
 * Fee Schedule

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CLAIM REVIEW AND APPEAL

The following information does not apply to Medicare Advantage and HMO claims.
It is provided as a general resource to providers regarding the types of claim
reviews and appeals that may be available for commercial and Medicaid claims.
Participating providers should refer to their participating provider agreement
and applicable provider manual for information on specific provider claim review
or appeal rights. Non-participating providers may refer to information about the
No Surprises Act.



Requesting a Claim Review

After adjudication, additional evaluation may be necessary (such as place of
treatment, procedure/revenue code changes, or out-of-area claim processing
issues).

For providers who need to submit claim review requests via paper, one of the
specific Claim Review Forms listed below must be utilized. Each Claim Review
Form must include the BCBSIL claim number (the Document Control Number, or DCN),
along with the key data elements specified on the forms.

 * Claim Review Form – Commercial only 
 * Additional Information Form – Commercial only 
 * Corrected Claim Form – Commercial only 
 * Medicaid Claims Inquiry or Dispute Request Form –  Medicaid only

Commercial Appeals

For more information related to Government Program appeals, please reference
applicable provider manuals.

A provider appeal is an official request for reconsideration of a previous
denial issued by the BCBSIL Medical Management area. This is different from the
request for claim review request process outlined above. Most provider appeal
requests are related to a length of stay or treatment setting denial.

 * Appeals may be initiated in writing or by telephone, upon receipt of a denial
   letter and instructions from BCBSIL
 * A routing form, along with relevant claim information and any supporting
   medical or clinical documentation must be included with the appeal request.
 * The physician/clinical peer review process takes 30 days and concludes with
   written notification of appeal determination.

A member appeal may be submitted by the member or their authorized
representative, physician, facility or other health care practitioner. Written
or verbal authorization from the member is required with the exception of urgent
care appeals. Brief descriptions of the various member appeal categories are
listed below.

 * A clinical appeal is a request to change an adverse determination for care or
   services that were denied on the basis of lack of medical necessity, or when
   services are determined to be experimental, investigational or cosmetic. May
   be pre- or post-service. Review is conducted by a physician.
 * A non-clinical appeal is a request to reconsider a previous inquiry,
   complaint or action by BCBSIL that has not been resolved to the member’s
   satisfaction. Relates to administrative health care services such as
   membership, access, claim payment, etc. May be pre-service or post-service.
   Review is conducted by a non-medical appeal committee.
 * Urgent care or expedited appeals may be requested if the member, authorized
   representative or physician feels that non-approval of the requested service
   may seriously jeopardize the member’s health. The physician or facility may
   request an expedited appeal by calling the number on the back of the member’s
   ID card.

 
 * Related Resources
 * Clear Claim ConnectionTM


 

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