The Record

Clarification: We’ve simplified your appeal process

What you need to know

To minimize your administrative steps, post‑service claim appeal requests can now be accepted verbally at the time you inquire about the status of a claim.
Appeals can no longer be submitted on the Blue Cross Blue Shield of Michigan Provider Appeals form.

An article on this topic in the September 2020 Record elicited some questions from providers. This new article is intended to clarify the changes in the appeal process.

Effective Oct. 1, 2020, the level 1 provider appeals process transitioned to Provider Relations & Servicing. Your claim appeal requests can now be accepted verbally at the time you inquire about the status of a claim. Also, the fax number that was used to submit documentation regarding appeals prior to Oct. 1, 2020, has changed.

The changes implemented on Oct. 1, 2020, only apply to Blue Cross Blue Shield of Michigan post-service commercial appeals.

As always, your first step if you want to appeal an adverse benefit or claim determination is to call Provider Inquiry. You may contact a Customer Service representative at one of the phone numbers below.

Medical providers: 1‑800‑344‑8525

Facility providers: 1‑800‑249‑5103

Vision and hearing providers: 1‑800‑482‑4047

Refer to the “Appeals and Problem Resolution” chapter of the PPO Provider Manual on web‑DENIS for a detailed explanation of appeal filing criteria and guidelines.

Submitting documentation for review
If you’re eligible to appeal and need to submit additional documentation for review, you no longer need to complete a Provider Appeals form. The representative you speak with will send you a prepopulated Provider Level 1 Appeals Fax Cover Sheet.

Once you gather your documentation, return it to Blue Cross Blue Shield of Michigan Provider Relations & Servicing by fax at 1‑866‑434‑6911, ensuring that the fax cover sheet from the Customer Service representative is the first page of your fax. This fax cover sheet will replace the cover sheet previously used by your office. Note: All faxes must include the Provider Level 1 Appeals Fax Cover Sheet provided by the Customer Service representative.

Appeals not affected by this process
Blue Care Network commercial, BCN Advantage^SM, Medicare Plus Blue^SM, Medicare Private Fee for Service, Federal Employee Program^®, Blue Cross Complete, prior authorization appeals and clinical editing appeals aren’t affected by these changes. Continue to follow the established processes for these appeal types.

For more information, see the September Record article.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.