Blue Cross Blue Shield of North Dakota (BCBSND) wants to remind providers of the importance of marking an appeal as urgent appropriately.
An urgent (expedited or emergent) appeal should be used only when waiting for a standard review could harm the patient.
Federal guidance defines an urgent appeal as one where a delay could seriously jeopardize the patient’s life, health, or ability to regain or maintain maximum function.
Appropriate Use
Providers should mark an appeal as urgent when there is clear, time-sensitive clinical risk, such as:
- Potential for rapid condition worsening
- Risk of loss of function or recovery
- Severe, uncontrolled symptoms or pain
- Interruption of ongoing or necessary treatment
Documentation Expectations
To support an urgent appeal, providers should:
- Clearly describe the clinical risk of delay
- Include supporting medical records or physician rationale
- Provide a direct phone number or contact informationfor timely communication and follow-up
Key Takeaway
Use the urgent designation only when the patient cannot safely wait—and ensure documentation clearly explains why immediate review is necessary and how the plan can quickly reach you if needed.
To find more information on appeals you can view the applicable resources below:
- Medicaid Expansion provider manual
- Commercial provider manual
- Appeals webpage
Questions?
Contact the applicable Provider Service Contact Center as noted on the members ID card on our contact us page.
