Appeal Process for ND Medicaid Expansion Providers
BCBSND administers coverage for North Dakota’s Medicaid Expansion Program. If a provider or enrolled member disagrees with a BCBSND benefits determination, the decision may be appealed.
Three types of benefit appeals
1. Standard Pre-Service Request
- Members have the right to appeal
- Providers filing a pre-service appeal request on behalf of a Medicaid Expansion member, assume responsibility to act on behalf of the Member. An Authorization to Release Information (ARI) is not required.
- BCBSND responds in writing within 30 days.
2. Pre-Service Expedited Appeal
- Members have the right to appeal
- Providers filing a pre-service appeal request on behalf of a Medicaid Expansion member, assume responsibility to act on behalf of the Member. An Authorization to Release Information (ARI) is not required.
- BCBSND responds verbally within 72 hours, followed by a written response within three days.
3. Post Service
- Providers or members have the right to appeal
- If a provider is appealing on behalf of an enrolled member, a signed and dated Authorization to Release Information Form must be included with the request
- BCBSND responds in writing within 30 days.
Response timelines
The timelines for standard or expedited appeals may be extended by up to 14 days if:
- The member or member’s authorized representative requests the extension
- BCBSND requires additional information, and the delay is in the enrolled member’s interest
Additional details on extended timelines are available in the Medicaid Expansion Provider Manual.
If BCBSND fails to follow these timeline requirements, the enrolled member will have exhausted the BCBSND appeal process and may initiate a state fair hearing.
Appeal process
An individual enrolled in Medicaid Expansion, their provider or an authorized representative may file an appeal to an Adverse Benefit Determination within 60 days.
The appeal is considered by a BCBSND staff member not involved in the original determination or their subordinate. The decision maker may be a health care professional with appropriate clinical expertise, and the decision maker may consider information that was not part of the initial determination.
BCBSND provides a notice of the appeal resolution within the time frames noted above. View the full Appeals Process
If the resolution is not wholly in the member’s favor, BCBSND includes information about:
- The right to request a state fair hearing within 120 days of the notice of resolution. View the process for a state fair hearing.
- The right to request the continuation of disputed services in certain situations and how to request service continuation.
- How the member may be liable for the cost of disputed services provided if the state fair hearing decision upholds BCBSND’s Adverse Benefit Determination.
How to file an appeal
Prefer to print form and submit?
Provider Appeals Form
Phone: 1-833-777-5779, Monday through Friday, 8 a.m. to 5 p.m. CST
Mail: Blue Cross Blue Shield of North Dakota
PO Box 1570
Fargo, ND 58107-1570
Grievance process
If a provider, an enrolled member, or member’s authorized representative is dissatisfied on a matter other than an Adverse Benefit Determination, a verbal or written grievance may be filed with BCBSND.
Phone: 1-833-777-5779, Monday through Friday, 8 a.m. to 5 p.m. CST
Mail: Blue Cross Blue Shield of North Dakota
PO Box 1570
Fargo, ND 58107-1570
Claims correction
Appeals cannot be requested for claim corrections. To correct, void or cancel claims, use the claims correction process on Availity Essentials.
