Provider appeal process

As BCBSND members transition to new systems, policies and processes throughout 2027, providers should continue using the same appeal form, submission channels and appeal timelines unless otherwise instructed in a denial, determination or audit letter. Appeal requirements may vary based on the type of determination appealed and the member’s migration status. Information about these variances are provided on this page.

Migrated members: Certain claim review, audit, reimbursement or coding determinations may require providers to follow new instructions included in the determination letter. Appeal and reconsideration processes may vary based on the type of review conducted.

If you disagree with a BCBSND determination, you may appeal.

Types of benefit appeals

For all members: 

Pre-service claim for benefits appeals can be either verbal or written.

• For standard appeals, BCBSND will respond in writing within 30 calendar days
• For emergent appeals, BCBSND will respond verbally within 72 hours, followed by a written response within three calendar days.

Retrospective review claim for benefits appeals can be either verbal or written.

• BCBSND will respond in writing within 30 calendar days.

Post-service claim for benefits appeals must be written.

• BCBSND will respond in writing within 60 calendar days.

Appeal process guidelines for providers

For all members:

• Continue using the current appeal process unless the denial, audit determination or review letter provides different appeal or reconsideration instructions.
• Appeals must be received within 180 days of the adverse benefit determination. Appeals received after 180 days will be returned without review.
• Specifically state the nature of the appeal and include all supporting information and rationale. You may submit written comments, documents and records or other related documents with your appeal.
• BCBSND will take all the information into account during the appeal process regardless of whether it was part of the original determination.
• Your appeal will be considered by a BCBSND medical director/medical consultant not involved in the original decision. The individual will be board certified in the same or similar specialty. He or she will not be a subordinate of the original decision maker.
• If the initial denial is overturned, BCBSND will explain in writing within the timeframes noted above.
• If additional documentation is requested during an appeal or review, providers should submit all supporting records indicated in the appeal instructions.

More information regarding Appeals can be found in the  Provider Manual.

Retail and medical drug benefit (pharmacy) appeals

Appeal processes for retail and medical benefit drug requests may differ depending on the member’s migration status.

For non-migrated members:

• Retail and medical benefit drug appeals continue to be supported by the health plan.

For migrated members:

• Medical drug benefit appeals will be reviewed by the health plan. 
• Retail drug benefit appeals will be supported by Prime Therapeutics.

Providers should follow the appeal instructions included in the denial letter.

Vendor-managed services appeals

For migrated members:

Appeal and peer-to-peer review processes for certain vendor-managed services will differ.

• For EviCore by Evernorth (EviCore) managed services for the Physical Medicine program, first-level appeals and peer-to-peer discussions are handled by EviCore. Subsequent appeal levels are reviewed by BCBSND.

Providers should follow the appeal instructions included in the denial letter..

Disputes and reconsiderations

For all members:
Providers should continue using the existing appeal form and submission process for migrated and non-migrated members, unless instructed otherwise.

For migrated members:
Some claims review and reimbursement determination processes will change.

• Certain review programs may include separate reconsideration processes, which will be described in the determination letter.
• Appeals, disputes and reconsiderations are reviewed by different teams depending on the issue being raised.

How to file an appeal

For all members:

Prefer to print form and submit?

1. Complete Sections A, C and D of the  Appeal Form

2. Include additional information and documentation you think will help overturn the original decision. Requests submitted without documentation will be denied as an invalid appeal.  
   Note: Do not use the Appeal Form to submit a claim correction, medical record or EOB.

3. Follow the instructions on the form to fax it or return it via mail.