| Providers can submit an appeal for the following reasons: |
Please don't submit appeals for: |
- Clinical edit disagreements – (include supporting documentation that shows correct billing)
- Medical necessity denials (provider write-offs)
- Allowed amounts that disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials
- Claims denied for timely filing
|
- Billing errors
- Duplicate or eligibility denials
- Corrected claims
- Claims denied for needing medical records, incident questionnaires, or other additional processing information
- Other coverage denials like coordination of benefits, worker’s comp or subrogation
|
Note: Carewise audit appeals should go directly to Carewise as noted in the letter sent to providers.
Appeals
When submitting an appeal on behalf of a member, make sure
to use the correct form to get the fastest response. Please take a moment to double-check any forms you may have
bookmarked and make sure you’re sending us the right appeal form for the
member’s plan.
You can choose from one of
the following appeal forms that corresponds with the member’s plan:
Premera commercial plans provider appeal form - Note the different fax numbers for clinical vs. general appeals. Member authorization
is embedded in the form for providers submitting on a member's behalf (section C).
Premera Blue Cross HMO appeal form
Premera individual plans provider appeal form
Premera Medicare Advantage plans provider appeal form
Federal Employee Program (FEP) plans provider appeal form
BlueCard plans provider appeal form - For out-of-area BlueCard members appealing the home Blue plan.
For LifeWise Health Plan of Washington appeal forms, visit their provider websites: LifeWise individual plans or LifeWise group plans.
Policy reconsideration
Policy reconsideration - Request reconsideration of a coding policy.