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Appeal/Reconsiderations
Q. Where do we send appeals?
A. You should send your request to the same address you filed the claim, which will be BCBSTX in most instances. They should be sent with a completed Provider Request for Claim Appeal/Reconsideration Form attached on the top. If you are instructed to file your claim direct to another plan, then all correspondence to include appeals should be sent directly to that plan also.
Q. Do we have to file a corrected claim in its entirety or just the line item?
A. Complete the Provider Request for Claim Appeal/Reconsideration Form with your corrected claim attached. The comments section should state what is being corrected on the claim.
Q. Do we have to use the Provider Request for Claim Appeal/Reconsideration Review form?
A. Beginning April 1, 2004, the BCBSTX Provider Request for Claim Appeal/Reconsideration Review Form is required for all claim appeals.
Q. We have problems when we send in appeals. We are told that BCBSTX has no record of the appeal. Why?
A. Using the Provider Request for Claim Appeal/Reconsideration Review Form will help ensure your request is routed to the appropriate area for processing. The form and instructions can be located in the Downloadable Forms section on the provider Web site.
Q. Is a claim number required on the appeal form?
A. Yes, the claim number should be listed in the appropriate box. This eliminates the need for you to submit a paper copy of your claim when submitting an appeal.
Q. When we appeal and the claim continues to deny, can BCBSTX give a specific reason?
A. Process improvements are being made in this area. However, if no additional information is received with your appeal and/or reconsideration request, BCBSTX may continue to uphold the original payment determination without specific details.
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