We’re simplifying provider appeals process

As part of our efforts to simplify administrative processes for health care providers, we’ve made some changes to the claim inquiry and appeals processes. Keep in mind that it’s no longer necessary to reach out to your provider consultant as part of the process. Here’s an overview of how the appeals process works.

Step one: To inquire about an adverse benefit or claim determination, contact Provider Inquiry.

• 1-800-344-8525 for medical providers
• 1-800-482-4047 for vision and hearing providers
• 1-800-249-5103 for facility providers

Step two: If your issue couldn’t be resolved after contacting Provider Inquiry and you have additional information to provide, you may file a written appeal request with Blue Cross Blue Shield of Michigan. Your written request must be received within 30 calendar days from the date you contacted Provider Inquiry.

Background: Providers may file a written appeal for an adverse benefit or claim determination within 30 days of completing the routine inquiry procedure and within 180 days from the date of claim determination.

The following are examples of reasons a provider may receive an adverse claim or benefit determination:

• Lack of benefits or reduction of benefits
• Services that are considered experimental or investigational
• Lack of medical necessity
• Lack of precertification (not obtained as required)
• Pricing disputes
• Sanctions due to cost containment programs
• Facility rejections related to length of stay or appropriateness of treatment setting

You may submit your written appeal request on your office letterhead or use the Provider Appeal Form. The form was recently revised and can be accessed from the Forms page of web-DENIS as follows:

• From the home page of web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Forms in the left column.

In your appeal request, include the following:

• The documentation you referenced when you contacted Provider Inquiry
• The reason you’re appealing
• Supporting documentation
• The enrollee’s ID (including the three-character alpha-numeric prefix)
• The patient’s name and the date(s) of service

Send the written appeal request or the completed Provider Appeal Form and all supporting documentation by fax to 1-877-348-2210 or by mail to:

Blue Cross Blue Shield of Michigan
Provider Appeals — Mail Code CS3A
600 E. Lafayette Blvd.
Detroit, MI 48226

We’ll respond to your appeal within 30 calendar days.

Note: Your appeal will be returned if it’s missing information or doesn’t meet the time frames outlined above.