We’ll return clinical editing appeals that don’t include a rationale

Effective immediately, when we receive a clinical editing appeal that doesn’t include a rationale, we’ll return it to the provider without review. We’re doing this because when an appeal doesn’t include a rationale, it makes it difficult to determine the basis for the appeal.

What a rationale must show

A rationale must describe why you think the services meet the criteria for reimbursement. It must be related to:

• Blue Cross Blue Shield of Michigan or Blue Care Network payment policies
• Coding guidelines specific to the denied services that were provided to the member on the dates of service identified in the appeal

All clinical editing appeals must have a rationale that conforms to these requirements or they will be returned to the provider without review. 

How to submit a clinical editing appeal

To appeal a claim denied for clinical editing, access the Clinical Editing Appeal Form and follow the instructions on the form to complete and submit it.

Be sure to do the following:

• Complete all the required fields. These are marked with a red asterisk on the form (fields 1 through 16).

  Note: In field 16, be sure to include the rationale for the appeal as described above.

• Include supporting documentation of the types listed in field 17 on the form:
• Chart or office notes, when the code being appealed refers to an office visit or a service provided in the office
• Operative notes or surgery reports, when the code being appealed refers to a surgery
• X-ray reports, when an X-ray is being appealed
• Lab or pathology reports, when a laboratory or pathology service is being appealed