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 health care 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 has contracted with an independent review agency to conduct independent external reviews.
BCBSND will provide the medical information and medical policies used in the provider appeal process. The Request for Independent External Review form can be found at BCBSND Forms and Documents under Claims Processing.
The Independent External Review process does not apply to the following. Requests will be returned to the provider:
- Benefit Plan exclusions
- Federal Employee Program (FEP)
Questions?
For more information regarding this process, please see the BCBSND Provider Manual. This manual will be updated within the next 60 days to remove the self-funded employee benefit plans.
