Contracted providers with Blue Cross’ Medicare Advantage PPO have their own appeals rights. Providers may appeal decisions on denied claims, such as denial of a service related to medical necessity and appropriateness.
Providers may also dispute a payment made to them by the Medicare Advantage PPO plan that is less than the payment amount that would have been paid under the Medicare fee schedule. Blue Cross' Medicare Advantage PPO providers should follow the guidelines on this page when submitting an appeal.
Michigan providers can either call or write to make an appeal or file a payment dispute. Call 1-866-309-1719 or write to us using the following address:
Medicare Plus Blue
P.O. Box 33842
Detroit, MI 48232-5842
If you are a dentist, write to us and send to the address listed below for dental providers.
Initial appeal requests for a claim denial must be submitted within 60 days from the date the provider receives the initial denial notice. Be sure to include the following information with your written appeal:
If you believe that we have reached an incorrect decision regarding your first-level appeal, you may file a request for a secondary review of this determination. A request for secondary review must be submitted in writing within 60 days of written notice of the first-level decision from Medicare Plus Blue. Decisions from this secondary review will be final and binding. Be sure to include the following information with your written appeal:
Payments must be disputed within 120 days from the date payment is initially received. We will review your dispute and respond to you within 60 days from the time we receive notice of your dispute. If we agree with your position, then we will pay you the correct amount. We will inform you in writing if your payment dispute is denied. Be sure to include the following information with your written request:
If you still believe that we have reached an incorrect decision regarding your payment dispute, you may file a request in writing for a secondary review of this determination within 60 days of receiving written notice of our first level decision. To request a secondary review of this determination, write to:
Medicare Advantage PRS – Appeals
Attn: Second Level Payment Dispute Blue Cross
P.O. Box 441160
Detroit, MI 48244-1160
Write to the following address:
Blue Cross Blue Shield of Michigan
P.O. Box 49
Detroit, MI 48231
If you disagree with the decision made on your first appeal, you may request a managerial level review conference within 60 days of receiving the original decision. The address to request your managerial level review conference is:
Medicare Advantage Dental Provider Grievances & Appeals (second level)
600 E. Lafayette – Mail Code 517K
Detroit, MI 48226
Be sure to include the following information with your request for a secondary review:
For retroactive audit disputes, the appeals process contains the following steps:
1. Internal Review: You may submit a written request that documents the cases being appealed for an internal review within 50 days of receiving our audit determination. You may also submit additional information to support your position. Within 50 calendar days of receiving your request, we will send you our determination. You may further appeal this determination by requesting an external appeal
2. External Peer Review: You may submit a written request that documents the cases being appealed for an external peer review within 20 days of receipt of our internal review determination. Only previously submitted information will be used for this review. Within 50 calendar days after your submission of medical records, the review organization communicates its determination, which is binding for both of us. If our decision is upheld, you pay the review cost. If our decision is reversed, then we absorb the cost. If our findings are partially upheld and partially reversed, we share the review cost with you in proportion to the results. This ends the appeal process.