Reminders: Important Appeal Tips

Impacting both Commercial and Medicaid Expansion

Blue Cross Blue Shield of North Dakota (BCBSND) is seeing an increased number of appeals for both our Commercial and Medicaid Expansion lines of business. We would like to remind our provider community of some important tips when submitting an appeal request to avoid delay and denial.

Commercial Tips

  1. Use of the online appeals form
    1. Assists in streamlining the process for a faster review and a quicker response.
    2. Access the online form at Provider Appeal Form (Online Version).
  2. Commercial Appeal submission time limits
    1. The appeal must be received one hundred eighty (180) days from the adverse determination for both pre and/or post service.
    2. The appeal must be received within one hundred eighty (180) days of the date BCBSND notifies the health care provider or member of the precertification result and/or the appeal must be received within 180 days of the date BCBSND notifies the health care provider or member of the claim for benefits determination.
  3. Commercial claims past timely filing limits
    1. The required time limit for new commercial claim submissions. All professional (837P) and institutional (837I) claims must be filed electronically, unless noted otherwise and received within the following time limits:
    2. Three hundred sixty-five (365) days of the date of service
    3. Some exceptions apply specifically to third-party liability and the Veterans Administration services.
  4. No precertification on file
    1. Claims submitted without precertification review will be denied, and no additional post-claim review will be completed.
    2. To assist in making sure services are covered based on precertification requirements it is very important to have the approved precertification in place before the claim is submitted.
    3. When services are not this will result in providers being held liable for charges.
  5. Supporting documentation on appeals
    1. Providers are sending in excessive amounts of information that does not relate to their appeal.
    2. Providers should send only what is minimally necessary to support their appeal.


For more information regarding the appeals process, refer to the Commercial Provider Manual (bcbsnd.com) appeals section for assistance.

Medicaid Expansion Tips

  1. Use of the online appeals form
    1. Assists in streamlining the process for a faster review and a quicker response.
    2. Access the online form at Provider Appeal Form (Online Version).
  2. Medicaid Expansion Appeal submission time limits
    1. The appeal must be received sixty (60) days from the adverse determination for both pre and/or post service.
    2. The appeal must be received within sixty (60) days of the date BCBSND notifies the health care provider or member of the precertification result and/or the appeal must be received within 60 days of the date BCBSND notifies the health care provider or member of the claim for benefits determination.
  3. Medicaid Expansion claims past timely filing limits
    1. Claims submitted outside of the time limits will be denied unless BCBSND or its subcontractors created the error.
    2. The required time limit for new Medicaid Expansion claim submissions. All professional (837P) and institutional (837I) claims must be filed electronically, unless noted otherwise and received within the following time limits:
      1. One hundred eighty (180) days of the date of service
      2. One hundred eighty (180) days from the enrollee’s retroactive coverage notification
      3. Three hundred sixty-five (365) calendar days from the date of service for claims involving third-party liability
  4. No precertification on file
    1. Claims submitted without precertification review will be denied, and no additional post-claim review will be completed.
    2. To assist in making sure services are covered based on precertification requirements it is very important to have the approved precertification in place before the claim is submitted.
    3. When services are not this will result in providers being held liable for charges.
  5. Supporting documentation on appeals
    1. Providers are sending in excessive amounts of information that does not relate to their appeal.
    2. Providers should send only what is minimally necessary to support their appeal.

For more information regarding the appeals process, refer to the Medicaid Expansion Provider Manual (bcbsnd.com) appeals section for assistance.

Questions?
Contact our Provider Service Centers:

  • Commercial: 1-800-368-2312
  • Medicaid Expansion: 1-833-777-5779