888-765-5400Blue Cross and Blue Shield Gives You The Right to Appeal
Have you ever been denied payment for a claim and didn’t agree with the decision? Has your doctor ever recommended services for you that BCBSNC did not authorize and you didn’t know why? According to the BCBSNC Appeals Department, there are three common reasons that payment for services is denied or benefits are reduced:
- The service may not be medically necessary.
- The service is not covered under your health plan
- The service was provided by a nonparticipating doctor (not in the BCBSNC network).
To determine whether the services you required are covered by your health plan, carefully review your benefits in your Member Guide. If you still can’t determine whether the services are covered, a BCBSNC Customer Service representative can help you review your benefits. If you still disagree with the denial of payment or service, you have the right to appeal by following the process outlined below.
The Appeals Process
Level One: At this level, you can appeal the decision by submitting a written request that includes a description of the situation and a full explanation of why you disagree with the outcome. Be sure to supply any documentation that supports your position. BCBSNC will review this information. If you disagree with the outcome, then, in most instances, you can proceed to the next level of the appeals process.
Level Two: Please refer to your Member Guide for specific details regarding the Level Two process.
Level Three: This level is handled through the North Carolina Department of Insurance (NCDOI). You may request a review through the NCDOA for all medical denials.
The information above is brought to you from BCBSNC, A Guide to a Healthier You, 2009.
For more information on health insurance coverage in North Carolina and how to utilize My Member Services, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents. Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC). You may qualify for a 15% healthy lifestyle discount if you are in excellent health. Call us for details.