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Provider Appeals and Billing Disputes

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Anthem Blue Cross and Blue Shield Appeal Process  
Questions may be posed about the member’s health benefit plan. Since most questions can be handled informally, these questions should be addressed by contacting Member Service/Customer Service utilizing the telephone number provided on the back of the member’s identification card, while participating providers should call 1-800-922-3242. In addition, information about the following Appeal process may be obtained by contacting Member Service/Customer Service.  
APPEAL PROCESS  
The Appeal process is available to the member, the provider, or the duly authorized representative of the member or provider. This Appeal process applies to any adverse utilization review determination (which is considered an adverse pre-service claim determination) or any adverse non-utilization review determination (which is considered an adverse post-service claim determination) that involves a denial, reduction or termination of, or a failure to make payment to or on behalf of a member, in whole or in part, for a benefit under the member’s health benefit plan. Utilization review determinations, such as prior authorization or concurrent review, are determinations where receipt of a benefit, in whole or in part, is conditioned upon approval of the benefit in advance. Non-utilization review determinations concern issues relating to the member’s health benefit plan such as eligibility for benefits, coverage of claims, or claims processing.  
FIRST LEVEL APPEAL  
If a determination is not satisfactory, this is considered an adverse utilization review determination or an adverse non-utilization review determination and a First Level Appeal review may be requested. The First Level Appeal review request can be initiated orally, electronically or in writing within one hundred eighty (180) days from the date that the initial adverse utilization review determination or the adverse non-utilization review determination is received. Written First Level Appeal review requests should be mailed to:  

Anthem Blue Cross and Blue Shield
First Level Appeal Review
P.O. Box 1038
North Haven, CT 06473-4201

 
A First Level Appeal review request should include copies of any additional documentation supporting the Appeal. A First Level Appeal determination will be issued, in writing, within fifteen (15) days from the date that the First Level Appeal review request is received regarding an adverse utilization review determination or within thirty (30) days from the date the First Level Appeal Review request is received regarding an adverse non-utilization review determination.  
If the First Level Appeal determination regarding an adverse utilization review determination is not satisfactory, a member of a fully insured health plan or a self-insured governmental health plan which is not subject to the Employee Retirement Income Security Act of 1974 (ERISA), who is diagnosed with a condition that creates a life expectancy of less than two years and the denial is based on the grounds that the proposed service is experimental, may seek information (including the application) regarding an external appeal process administered by the Insurance Department without completing the Second Level Appeal review request through Anthem Blue Cross and Blue Shield.  
SECOND LEVEL APPEAL  
If the First Level Appeal determination is not satisfactory, a Second Level Appeal review may be requested. The Second Level Appeal review request can be initiated orally, electronically or in writing to the Second Level Appeal Panel within sixty (60) days from the date that the First Level Appeal determination is received regarding an adverse utilization review determination or within ten (10) days from the date that the First Level Appeal determination is received regarding an adverse non-utilization review determination. At this time, an in-person presentation, telephonic conference, videoconference or conference via other form of acceptable technology may be requested. If the Second Level Appeal review request regarding an adverse non-utilization review determination is received by Anthem Blue Cross and Blue Shield more than ten (10) days from the date that the First Level Appeal determination is received, the time period in excess of that ten (10) days will be considered a request for an extension by the member. Such an extension shall be granted for a period of up to sixty (60) days from the date that the First Level Appeal determination is received. Written Second Level Appeal requests should be mailed to:  

Anthem Blue Cross and Blue Shield
Second Level Appeal Panel
P.O. Box 1038
North Haven, CT 06473-4201

 
A Second Level Appeal review request should include copies of any additional documentation supporting the Appeal. A Second Level Appeal determination will be issued in writing within fifteen (15) days from the date that the Second Level Appeal review request is received regarding an adverse utilization review determination or in writing within twenty (20) days from the date that the Second Level Appeal review request is received regarding an adverse non-utilization review determination.  
LEGAL RIGHTS  
If the member’s health benefit plan is sponsored by the member’s employer, and is subject to the requirements of the Employee Retirement Income Security Act of 1974 (ERISA), and the member is dissatisfied with any decision after the Second Level Appeal determination is rendered, the member has a right to bring a civil action under §502 (a) of ERISA.  
OTHER MEMBER RIGHTS  
In the event of an emergency or life-threatening situation, or when a claim involves urgent care, or when a member who is diagnosed with a condition that creates a life expectancy of less than two years and the denial is based on the grounds that the proposed service is experimental, an Expedited First or Second Level Appeal review may be requested. A determination will be issued within 1 business day from the date the expedited First or Second Level Appeal review request is received.
The member is entitled to receive upon request and free of charge, reasonable access to, and copies of, any documents, records, and other information relevant to the member’s claim for benefits.
If an internal rule, guideline, protocol, or other similar criterion is relied upon in making the adverse utilization review or non-utilization review determination, the specific rule, guideline, protocol, or other similar criterion will be provided to the member free of charge upon request.
If the adverse determination is based on a medical necessity, or experimental treatment, or other similar exclusion or limit, an explanation of the scientific or clinical judgment for the determination applying the terms of the health benefit plan to the member’s medical circumstances will be provided free of charge upon request.
If a consultant’s advice was obtained in connection with a member’s adverse determination, without regard to whether the advice was relied upon in making the benefit determination, the consultant will be identified upon request.
After completion of both the First and Second Level Appeals for an adverse utilization review determination or an adverse non-utilization review determination based on medical necessity, a member, the provider or the duly authorized representative of the member or provider will receive information (including the application) regarding an external appeal process administered by the Insurance Department. An external appeal must be submitted to the State of Connecticut Insurance Department within sixty (60) days from the date of the Second Level Appeal determination. The member must first exhaust all of the utilization review company’s internal appeal mechanisms UNLESS it is determined that the time frame for completion of an expedited internal appeal may cause or exacerbate an emergency or life threatening situation. In an emergency or life threatening situation, the member, or provider acting on behalf of the member with the member’s consent, would not need to exhaust all internal appeals in this situation in order to file for an external appeal. The expedited appeal application must be filed with the Insurance Department immediately following receipt of the utilization review company’s initial adverse determination or at any level of adverse appeal determination.  If the expedited external appeal is not accepted on an expedited basis, and the member has not previously exhausted all internal appeals, the member may resume the internal appeal process until all internal appeals are exhausted and then may file for a standard external appeal within 60 days following receipt of the final denial letter. If all internal appeals were previously exhausted, the member’s rejected expedited external appeal will automatically be eligible for consideration for standard external appeal. The member is not required to submit a new application.
The external appeals process is not available to members who are covered under a non-governmental self-insured plan or to denials regarding workers compensation.
The member, the provider, or the duly authorized representative of the member or provider may, at any time, seek further review of an adverse determination by writing to the Insurance Commissioner at: State of Connecticut, Insurance Department, Consumer Affairs, P.O. Box 816, Hartford, Connecticut 06142, or by calling (860) 297-3910.
 
Revised 10/09  
 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use