Please complete a separate claim form in full for each hospital and/or doctor bill being submitted.
The itemization must include the patient’s name, the service provided, service date, cost for each service, diagnosis, and the provider’s name and tax ID number. For all other servicesįile one claim per patient and attach an itemized bill from the service provider.
The proof of service must include patient’s name, prescription name, and prescription Rx number, National Drug Code, quantity, number of days supply, service date, cost for each prescription plus the complete name and address of the pharmacy, and the pharmacy tax ID number. For prescription drug claimsįile one claim per patient and attach an itemized bill from the pharmacy with the pharmacist’s signature or the pharmacy receipts. This form may also be obtained by contacting our customer service center at 80. If the provider is non-contracting and does not agree to file the claim or the member has a prescription benefit in which filing a claim is required for reimbursement, the member may access the Forms section to obtain the correct claim form. The physician or facility may request an expedited appeal by calling the number on the back of the member's ID card.If the member receives covered services from a contracting provider, a claim will be filed on their behalf by the provider. Urgent care or expedited appeals may be requested if the member, authorized representative or physician feels that non-approval of the requested service may seriously jeopardize the member's health.Review is conducted by a non-medical appeal committee. Relates to administrative health care services such as membership, access, claim payment, etc. A non-clinical appeal is a request to reconsider a previous inquiry, complaint or action by BCBSMT that has not been resolved to the member's satisfaction.A clinical appeal is a request to change an adverse determination for care or services that were denied on the basis of lack of medical necessity, or when services are determined to be experimental, investigational or cosmetic.Brief descriptions of the various member appeal categories are listed below. Written or verbal authorization from the member is required with the exception of urgent care appeals. The physician/clinical peer review process takes 30 days and concludes with written notification of appeal determination.Ī member appeal may be submitted by the member or their authorized representative, physician, facility or other health care practitioner.A routing form, along with relevant claim information and any supporting medical or clinical documentation must be included with the appeal request.Appeals may be initiated in writing or by telephone, upon receipt of a denial letter and instructions from BCBSMT.Most provider appeal requests are related to a length of stay or treatment setting denial. This is different from the request for claim review request process outlined above.
AppealsĪ provider appeal is an official request for reconsideration of a previous denial issued by the Blue Cross and Blue Shield of Montana (BCBSMT) Medical Management area. Log on to Availity ® to request a claim review and initiate a negotiation for NSA-eligible services.
After adjudication, additional evaluation may be necessary (such as place of treatment, procedure/revenue code changes, or out-of-area claim processing issues).