How to Appeal
Note: The following appeals forms should only be used by, or on behalf of, an Anthem Blue Cross and Blue Shield of Maine member.
If you, or our member, are dissatisfied with the recent determination we issued, you can file an appeal. An appeal must be filed within 180 days of the date we issued the adverse determination you are appealing. We are committed to responding to your concerns promptly and confidentially. An appeal of a medical necessity determination may be handled in an expedited manner if waiting for the appeal to be resolved using standard appeal time frames would seriously jeopardize our member’s life, health, or ability to regain maximum functioning. An expedited review will be completed within 72 hours after the request is initiated. The determination will be relayed via telephone, with written communication to be issued within two business days. The request may be initiated by the covered person or the provider acting on behalf of the covered person. If you would like to request an expedited appeal, please call 1-800-392-1016.
What should your appeal include?
Identify (by patient name, certificate or identification number, date of service, and, if available, by claim number) the specific determination with which you disagree. Explain the specific reason(s) why you do not agree with our determination. For inpatient hospital appeals, please include a copy of the entire medical record of the admission. For other types of appeals, please include all pertinent information regarding the care, especially any additional supporting documentation you would like us to review. Please also include your provider identification number.
How do you file an appeal?
Submit the appeal in writing to our Appeal Analyst, PO Box 218, North Haven, CT 06473-0218 or by e-mail using our secure online form
How will your appeal be handled?
Our appeal analyst will review the entire record of your appeal, including any additional supporting documentation you submit with your appeal, and will research and respond to the issues you have raised. If appropriate, we will include administrative specialists and/or a clinician with demonstrable expertise in our review process. We will issue a written decision within 20 working days of receiving your request for appeal.
If you disagree with the determination on your appeal, can you appeal further?
Along with our determination, we will provide you with information on how to appeal further, if applicable. If we deny your appeal and our determination is based on medical necessity, a pre-existing condition, or regarding an experimental or investigational service, the member may have the right to request an external review by an Independent Review Organization. The member has been provided with information regarding his or her rights.