The provider has 60 days from the date of the audit determination letter to request a reconsideration.
The provider waives any further opportunity for reconsideration or payment of the claim by not responding on time. After 60 days the claim is adjusted to reflect the audit finding. Requests for reconsideration after 60 days are not considered.
Within 60 days of receiving the reconsideration request and supporting documentation, the reviewer reviews the request, and a reconsideration determination letter is sent. The letter will include one of the following determinations:
Reconsideration Overturned
The vendor agrees with the claim submission. No further action is required.
Agree with determination:
Sign the reconsideration determination letter and return it to the address on the letter within 60 days of the letter date. BCBSND will adjust the claim to reflect the reconsideration determination within 60 days.
Disagree with determination:
Submit a second-level reconsideration request along with supporting documentation and a copy of the letter within 60 days to the reconsideration address provided on the letter.
A reconsideration determination is provided within 60 days
Overturned: No further action is required.
Upheld: No further action is required. BCBSND will adjust the claim to reflect the final audit determination.
Note: If a reconsideration is not requested within 60 days, the claim will be adjusted to reflect the audit determination. Any further opportunity for reconsideration or payment of the claim is waived by the provider for failure to respond timely.
For questions on your reconsideration notice, use the contact information in the reconsideration determination letter.
