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Provider appeal process

If you disagree with a BCBSND benefits inquiry determination, you may appeal the decision.

Need to request an appeal of a benefit determination?

Download Appeal Form

3 types of benefits appeals

1. Pre-service claim for benefits appeal—can be either verbal or written

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

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

  • BCBSND will respond in writing within 30 calendar days.

3. Post-service claim for benefits appeals—must be written

  • BCBSND will respond in writing within 60 calendar days.

Appeal process guidelines for providers

  • Appeals must be received within 180 days from inquiry 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 inquiry determination. 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 time frames noted above.

Download the Process for Provider Inquiries, Appeals and Grievances 

How to file an appeal

  1. Complete Sections A, C and D of the Appeal Form
  2. Include additional information you think will help overturn the original determination. 
    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. Return completed forms by: 
    Fax: (701) 277-2209
    or
    Mail: Blue Cross Blue Shield of North Dakota 
    PO Box 1570 
    Fargo, ND 58107-1570