Provider Appeals for Experimental/Investigational or Not Medically Necessary Services

Providers have the right to appeal a claim, which has been denied based on lack of medical necessity or service being experimental/investigational. If a provider is submitting a new diagnosis, a corrected claim or requesting review of the denial, this will be considered a first level or initial appeal. Providers should follow the Initial Appeal and Final Appeal process, when applicable, as outlined within the annual Policies & Procedures document.

If you have any questions regarding this newsletter, please contact your BCBSKS Institutional Relations provider consultant.