November 16, 2009

BC- 09-12
HP- 09- 09
SA- 09- 10
MS- 09- 11

HHA- 09- 09
DC- 09- 09
ASC- 09- 10

Cindy Garrison, Education/Communication Coordinator
Institutional Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association

BlueCard Provider Appeals

There are times when providers need to appeal a BlueCard member's prior authorization or claim.  The following will assistant you on where to submit your appeal.

Prior Authorization Appeals

Prospective

• The contracting BCBSKS provider contacts the member's *Home Plan regarding an upcoming admission.
• The Home Plan determines the approved length of stay.
• The Home Plan sends the benefit determination letter to the member and a copy to the provider.

Prior authorization denied

• The contracting provider contacts the member's Home Plan to authorize services for the member.
• The prior authorization is denied and the contracting provider is notified.
• The member is in the hospital when the determination letter is received.
• The provider, acting as the member's *authorized representative, contacts the Home Plan to provide additional information for the authorization.
• The Home Plan forwards the determination to the provider.

Retrospective

• The contracting provider contacts the member's Home Plan to authorize services for the member.
• The prior authorization is denied and the contracting provider is notified.
• Services have NOT been provided to the member.
• The contracting BCBSKS provider submits the appeal to Blue Cross and Blue Shield of Kansas (BCBSKS).
• BCBSKS works with the Home Plan regarding the appeal.
• BCBSKS forwards the determination to the contracting provider.

*In order for a provider to appeal on behalf of the member, a Member Authorization Form must be included with the appeal documentation.  Click here for a LINK to the form.

Claim Appeals

A provider claim appeal is a formal request for reconsideration of a previously processed claim which may or may not include additional information.  Formal provider claim appeals include, but are not limited to:

• Experimental/Investigational
• Medical Necessity
• MS-DRG assignment

The following are examples of what is not considered a formal provider appeal:

• Corrected claim
• Timely filing
• Deductible/coinsurance issues
• Eligibility issues
• Contract exclusions and/or benefit limitations
• Claims denials needing additional information

ALL provider claim appeals should be sent to BCBSKS. 

If a member wishes to appeal a claim, the member's appeal should be sent to their Home Plan.

Definition

*Home Plan:  Member's Plan that participates in the BlueCard Program. 

Helpful phone numbers

BlueCard® eligibility and claim status information is available on the BCBSKS Web site www.bcbsks.com (provider services section).