We’ve modified provider appeal time frames, effective June 1

In a March Record article, we let you know that changes were coming to how we’re handling provider audits and appeals. Here are the time frames associated with the provider audit appeals process for professional and non-hospital facility providers, beginning June 1, 2018.

For reconsideration appeal:

• The health care provider must request an appeal within 30 calendar days of the date on the reporting letter.
• The provider will receive a response to his or her appeal within 30 calendar days of the date the appeal is received.
• We’ll adjust claims as needed if we don’t receive a reconsideration appeal within 30 calendar days of the date of the audit finding.

For independent external review:

• We must receive the request for a review within 30 calendar days of the date of the reconsideration appeal letter.
• An external peer review of records will take place within 45 calendar days.
• The provider will be notified of the peer review decision within 30 calendar days of the date that the peer review decision is received.
• The provider will pay the cost of the peer review if our audit decision is upheld. If our audit decision is reversed, then we’ll absorb the cost. If our findings are partially reversed and partially upheld, we will share the peer review cost proportionate to the results.
• We’ll adjust claims as needed if we don’t receive a request for an independent external review within 30 calendar days of the date of the appeal uphold letter.

Note: Providers may incur attorney fees and other expenses in preparation for the external peer review; these costs are the providers’ responsibility. The external review ends the appeal process for both Blue Cross Blue Shield of Michigan and the provider.