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It is now easier for providers to go through the formal process of asking BlueCross to reconsider claims outcomes or denials, and to file formal appeals when necessary.
STEP 1: PROVIDER RECONSIDERATION
Providers may request a reconsideration if dissatisfied with a claims outcome/denial, or if they simply need to ask questions about a particular claim.
Provider reconsiderations may be requested in reference to numerous topics, including, but not limited to:
Providers may initiate a reconsideration by calling us or using the Provider Reconsideration Form. Reconsideration requests must be submitted within 18 months of the initial claims denial.
Please note that you can skip the reconsideration step. But that means waiving the right to more than one review and, if you’re unsatisfied, the dispute will go directly to binding arbitration.
STEP 2: PROVIDER APPEAL
If providers remain dissatisfied after a reconsideration, an Appeal may be filed to formally dispute the denial and provide additional documentation to BlueCross. Only one appeal is allowed per claim. Please use the Provider Appeals Form when submitting your request. Appeals must be filed and completed within 60 days of receiving a reconsideration determination. (Refer to this helpful guide for timeliness grids for each line of business.)
NOTE: If the reconsideration process identified the decision was related to medical necessity, you may be directed to a separate Utilization Management appeal form.
STEP 3: ARBITRATION
The arbitration process begins if providers are dissatisfied with the outcome of an appeal. Refer to the Provider Dispute Resolution Procedure documented in the BlueCross BlueShield of Tennessee Provider Administration Manual and/or the BlueCare Provider Administration Manual for more information.
Please refer to this helpful guide to better understand when and how to request reconsiderations or appeals. There are some variances in these processes depending on the line of business, which are outlined in this guide. Additionally, you may review the complete reconsideration process map and the complete appeals process map for additional guidance.