Blue Cross Newsletter
 

 

November 16, 2009

 

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


 

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

To: All Blue Cross Contracting Providers
From:

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

Subject:

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 Program
 - benefits and eligibility for out-of-area members

1-800-676-BLUE (2583)

BlueCard Program
 - claim inquiries for out-of-area members

1-800-432-3990 ext 4058

BlueCard Program
 - prior authorization

See the back of the member's card for Home Plan contact information.

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

 

CG