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Policy and Procedure for Provider Appeals Process

PW_A084594

Policy and Procedure for Provider Appeals Process - General

Introduction
Blue Cross Blue Shield of Georgia (BCBSGa) has an established process for providers to pursue resolution of issues related to administrative and contractual determinations. If a provider disagrees with our adjudication of a claim and has not received a satisfactory response from Customer Care, the provider has the right to appeal our initial determination. If the provider does not dispute or question a specific payment within 365 days of payment or determination, they shall be deemed to have waived all rights to dispute said payment.  
Definitions
INQUIRY
If a provider wishes to voice a concern or dissatisfaction with an issue, they may initiate an inquiry by sending a written notice or by contacting Customer Care using the contact information listed below. A Customer Care Associate will respond to the provider, either verbally or in writing, within 30 calendar days of receipt. 
For questions related to the BCBSGa code auditing system for claim logic, network providers should log on to Provider Access and select the Clear Claim Connection option. Based on the information obtained by prescreening claims and reviewing rationale from a claim denial, network providers can resolve their issue online and can avoid contacting the Plan.  
INTERNAL APPEAL
If the provider remains dissatisfied after receiving the inquiry response, they may initiate an internal appeal by sending the Provider Request for Review Form and substantiating documentation not previously submitted using the contact information below. The internal appeal decision will be sent in writing within 30 calendar days of receipt.  
Our Response
We will respond within 30 calendar days of receiving the provider’s request. Based upon the information submitted, we will.  
Uphold our original decision, or
Overturn our original decision
 
If We Uphold Our Original Decision  
We will send you a letter stating we are upholding our original decision and state our reason for the decision.
 
If We Overturn Our Original Decision  
We will send you a letter stating our decision and any additional payment due will appear on the providers remittance.
 
Contact Information
If the appeal is 10 pages or less, you can fax it to Provider Appeals at 888-859-3046.  
 
For larger documents, please mail to:  

BSBSGa
Attn: Provider Appeals
PO Box 105449
Atlanta, GA 30348-5449

© 2014 BlueCross BlueShield of Georgia
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.