Under certain circumstances, a provider may request an independent external review to determine if medical care provided was medically necessary and appropriate to the claim submitted by the healthcare provider and reviewed by Blue Cross Blue Shield of North Dakota (BCBSND). An independent external review may be requested only after exhausting BCBSND’s provider appeal process. BCBSND will provide the medical information and medical policies used in the provider inquiry and appeals process.
The Independent External Review process does not apply to the following and requests will be returned to
- Benefit Plan exclusions
- Self-funded employee benefit plans
- Federal Employee Program (FEP)
For more information regarding this process, please see the BCBSND Provider Manual.