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Physician/Professional Provider & Facility/Ancillary Request for
Claim Appeal/Reconsideration Review
Claim appeal/reconsideration review requests must be submitted in writing on the “Physician/Professional Provider & Facility/Ancillary Request for Claim Appeal/Reconsideration Review” form.
There are two (2) levels of claim appeals available to you.
For the following circumstances, the 1st claim appeal/reconsideration review must be requested within the corresponding timeframes outlined below:
Dispute Type |
Timeframe For Request |
| Audited Payment |
Within 30 days following the receipt of written notice of request for refund due to an audited payment |
| Overpayment |
Within 45 days following the receipt of written notice of request for refund due to overpayment |
| Claim Dispute |
Within 180 days following the date of the HMO Blue® Texas or the BCBSTX Provider Claims Summary (PCS) for the claim in dispute |
- BCBSTX / HMO Blue Texas will complete the 1st claim appeal/reconsideration review within 45 days following the receipt of your request for a 1st claim appeal/reconsideration review.
- You will receive written notification of the claim appeal/reconsideration review determination.
If the claim appeal/reconsideration review determination is not satisfactory to you, you may request a 2nd claim appeal/reconsideration review. The 2nd claim appeal/reconsideration review must be requested
within 15 days following your receipt of the 1st claim appeal /reconsideration review determination.
- BCBSTX / HMO Blue Texas will complete the 2nd claim appeal/reconsideration review within 30 days following the receipt of your request for a 2nd claim appeal/reconsideration review.
- You will receive written notification of the claim appeal/reconsideration review determination.
The claim appeal/reconsideration review process for a specific claim will be considered complete following your receipt of the 2nd claim appeal/reconsideration review determination.
Note: For those claims which are being appealed for timely filing, BCBSTX will accept the following documentation as acceptable proof of timely filing:
- TDI Mail Log
- Certified Mail Receipt (only if accompanied by TDI mail log)
- rEDI-link Blue Claim Acceptance Response Report
- Documentation indicating that the claim was timely filed with the wrong Blue Cross Blue Shield Plan and evidencing date of rejection by such Plan.
- Documentation from BCBSTX indicating claim was incomplete
- Documentation from BCBSTX requesting additional information
- Primary carrier's EOB indicating claim was filed with primary carrier within the timely filing deadline.
Mail the completed “Physician/Professional Provider & Facility/Ancillary Request for Claim Appeal/Reconsideration Review” form, along with any attachments, to the appropriate address indicated on the form.
If you have any questions concerning the process for claim appeal/reconsideration review, please contact your local Professional Provider Network office.
Updated 06/2008
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