We’re updating our MA PPO clinical editing appeals process

Blue Cross Blue Shield of Michigan Medicare Advantage PPO is updating its appeal process for clinical edits. Beginning Dec. 1, 2017, the following changes will take effect:

• There will be one level of appeal for clinical edit denials. These are claim denials in which the event code is either 870 or 852 (as noted on the paper voucher).
• Appeals must be submitted with a Clinical Editing Appeal form. All required fields must be completed or the appeal will be returned. The form can be found on the Blue Cross Provider site by clicking here.
• Submit the appeals form one of the following ways:
• Fax it to 1-866-526-7179
• Mail it to Clinical Editing Appeals
  Mail Code G820
  Blue Cross Blue Shield of Michigan – MA PPO
  611 Cascade West Parkway, SE
  Grand Rapids, MI 49546-2143
• Appeals must be submitted within 180 days of the original clinical editing denial.
• Documentation supporting the appeal must be submitted with the appeal. What is required may vary depending on the service being appealed. For example, office services that have been denied may require office notes, services denied as duplicates will require records for both the denied and paid service to show more than one was performed, and surgical denials may require operative reports. It’s important to look at the reason for denial and submit documentation appropriate to the procedure code that was denied and the denial reason.

This process is based on the Blue Care Network clinical editing appeals process. So, while the explanation codes and the fax number may be different, if you’ve had to submit an appeal to BCN in the past for a clinical edit, you’ve followed the process that will be in place for MA PPO. We believe it will allow us better tracking and timely resolution of your appeals.

If you have questions about the changes in the appeal process, call MA PPO Provider Inquiry at 1-866-309-1719 or contact your provider representative.