Under certain circumstances, a provider may request an independent external review to determine if medical care provided was medically necessary and appropriate only for determinations by Blue Cross Blue Shield of North Dakota (BCBSND) that are adverse to the member and based on medical necessity, appropriateness (including a determination that a treatment or service is investigative and/or experimental), health care setting, level of care and coding disputes based on medical necessity or effectiveness of a covered service or a rescission.
An independent external review may be requested only after exhausting BCBSND’s provider appeal process. The Independent External Review process does not apply to the following and requests will be returned to the provider:
- Benefit Plan exclusions
- Self-funded employee benefit plans
- Federal Employee Program (FEP)
For more information regarding this process, please see the BCBSND Provider Manual.
