Contracted Provider Appeals

Appealing Care Management Decisions 
Providers and practitioners who provide services for Medicare Advantage members have the right to appeal any denial decision made by BCBSNE. The provider appeals process for Medicare Advantage members, however, is governed by Medicare regulations. 

Provider appeals for care management decisions should follow the outlined below. For all other appeals, please refer to the grievance and appeal provider procedure.

Appeals of Claim Denials and/or Medical Necessity Denials  
(not related to retrospective audits)  
Contracted providers with BCBSNE Medicare Advantage plans have their own appeals rights. Providers may appeal decisions on denied claims, such as denial of a service related to medical necessity and appropriateness. Instead of following the member appeals process, BCBSNE Medicare Advantage providers should follow these guidelines when submitting an appeal.  

Calling Provider Inquiry Services is the first step in addressing a concern. If you are still unhappy with the decision after speaking with a representative, you may submit an appeal in writing to:

Appeals must be filed within 65 days from the date of the notice of the initial determination. Be sure to include appropriate documentation to support your appeal. We will review your appeal and respond to you in writing within 60 days from the time we receive notice of your appeal. 

If you believe that we have reached an incorrect decision regarding your appeal, you may file a request for a secondary review of this determination by mailing it to: 

A request for secondary review must be submitted in writing within 60 days of written notice of the first level decision from BCBSNE Medicare Advantage. We will review your appeal and respond to you within 60 days from the time we receive notice of your secondary review. Please provide appropriate documentation to support your appeal and a copy of the first level decision letter. Decisions from this secondary review will be final and binding.  

Appropriate documentation needed for a medical necessity appeal review:  

• Provider or supplier contact information including name and address 
• Pricing information, including NPI number (and CCN or OSCAR number for institutional providers), ZIP code where services were rendered and physician specialty 
• Reason for dispute-a description of the specific issue 
• Copy of the provider’s submitted claim with disputed portion identified 
• Documentation and any correspondence that supports your position that the plan’s denial was incorrect (including clinical rationale, Local Coverage Determination and/or National Coverage Determination documentation) 
• Appointment of provider or supplier representative authorization statement, if applicable 
• Name and signature of the provider or provider’s representative 

Appealing BCBSNE Decision- Two Level Provider Appeal Process-Post Service Denials for Urgent/Emergent Inpatient Admissions or Bundled Admissions  

Denials of care related to medical necessity or medical appropriateness are made by plan medical directors and are based on: 

• Review of pertinent medical information  
• Consideration of the member’s benefit coverage  
• Information from the attending physician and primary care physician  
• Clinical judgment of the medical director  

All contracted providers have the right to appeal an adverse decision rendered by the BCBSNE Care Management staff. The two-step appeal process is designed to be objective, thorough, fair and timely.   

At any step in the appeal process, a plan medical director may obtain the opinion of a same-specialty, board-certified physician or an external review board.   

When a provider appeal request is received and a member grievance is in process, the member grievance takes precedence. When the member appeal process is complete, the member appeal decision is considered to be final and the provider appeal request is not processed.