A written notice to Blue Shield challenging, appealing or requesting reconsideration of a claim, or requesting resolution of billing determinations, such as bundling/unbundling of claims/procedures codes (ClaimCheck) or allowances. Also, a written notice to Blue Shield disputing administrative policies & procedures, administrative terminations, retro-active contracting or any other contract issues.
Appeal Determination Date
The date Blue Shield's written determination in response to a provider Appeal is deposited in the U.S. mail.
A group of substantially similar multiple claims that are individually numbered using the Blue Shield assigned Internal Control Number (ICN) to identify each claim contained in the bundled appeal.
Or, a group of substantially similar contractual Appeals that are individually numbered using the section of the contract and sequential numbers that are cross-referenced to a document or spreadsheet. For example, 'Section I A #1, Section I A #2, etc.
Date of Contest, Denial, Notice or Payment
The date Blue Shield's claim decision, or payment, is electronically transmitted (835) or deposited in the U.S. mail (Explanation of Benefits).
Good Cause for Untimely Submission of Claims
Circumstances reasonably beyond the control of the provider that prevented the timely submission of a claim would be considered "good cause".
Examples of circumstances beyond the control of the provider, include, but are not limited to:
- Patient gave incorrect health coverage/insurance information (copy of an incorrect ID card)
- Patient was unable to provide health coverage / insurance information (patient was comatose, or the patient expired before the information could be obtained)
- Natural disaster/acts of nature (fire, flood, earthquake, etc.)
- System wide loss of computer data (system crash)
Examples of circumstances that do not constitute "good cause":
- Claim was sent to the wrong carrier (Blue Cross instead of Blue Shield), but the provider had the correct health coverage/insurance information.
- The claim was submitted timely, but Blue Shield was unable to process because the claim was not a complete claim (did not contain the minimum data elements to enter the claim into the system, i.e., missing subscriber number).
- Providers have an obligation to be responsible for appropriate timely billing practices.
- Provider requests to review a claim timely filing denial because the provider believes they had good cause for the delay, will be handled as a Provider Appeal.
A request for information, or question, regarding claim status, member eligibility, payment methodology rules (ClaimCheck logic, bundling/unbundling logic, multiple surgery rules), Medical Policy, coordination of benefits or third party liability/workers compensation issues. Inquiries include submission of corrected claims.
The working date when the provider Appeal is first delivered to the designated Provider Appeal post office box.
Unfair Billing Pattern
Engaging in a demonstrable and unjust pattern of bundling/unbundling or up-coding of claims, and/or other demonstrable and unjustified billing patterns.
Unjust or Unfair Payment Pattern
Any practice, policy or procedure that results in repeated delays in the processing and/or correct reimbursement of claims as defined by applicable regulations.