Provider Appeals

Providers may request reconsideration of how a claim processed, paid or denied. These requests are
referred to as appeals.

There are four different types of appeals:

• Coding and Payment Rule Appeals
• Utilization Management Appeals
• Adverse Determination Appeals
• All Others

If there is a reduction in payment or a denial of your claim, the remittance advice will provide an
explanation as to the reason for the reduction or denial of the claim.

Participating providers must submit appeals within one year of the date that appears on the respective
remittance advice. BCBSF will not overturn administrative claim denials based on the provider’s failure to
comply with required procedures and time frames.

Providers may not balance bill members for covered services; including disputed amounts. You may bill
members for applicable deductible, coinsurance and/or copayment and non-covered amounts per your
specific Agreement.

If an appeal is approved, the claim is forwarded for adjustment and/or payment. If an appeal is denied, a
letter is sent informing you of the denial.

Each appeal type is described in detail below.