Provider appeals

Blue Shield has established the following process to allow providers and capitated entities to submit Appeals.

Blue Shield's Provider Services Department is responsible for the Provider Appeal Resolution Process.

Blue Shield's Senior Management is responsible for:

• The maintenance of the Provider Appeal Resolution Process
• Review of the Provider Appeal Resolution operations
• Noting any emerging patterns to improve administrative capacity, Blue Shield Provider Relations, claim payment procedures and patient care
• Preparing the required reports and disclosures

Blue Shield's Provider Appeal Resolution Process consists of two levels: Initial and Final.

CCR, title 28, Section 1300.71.38 requires health plans to offer an appeal process. State law does not require health plans to offer two levels.

Initial appeals must be submitted in writing to:
Blue Shield Initial Appeal Resolution Office
       P.O. Box 272620
       Chico, CA 95927-2620

Initial appeals regarding facility contract exception(s) must be submitted in writing to:
Blue Shield Initial Appeal Resolution Office
       Attention: Hospital Exception and Transplant Team
       P.O. Box 629010
       El Dorado Hills, CA 95762-9010

An Appeal must be submitted in writing and contain the following information:

• The provider's name
• The provider's identification number: The Blue Shield Identification number (PIN) or the provider's tax or social security number
• Contact information: Mailing address and phone number
• Blue Shield's Internal Control Number (ICN), when applicable
• The patient's name, when applicable
• The patient's Blue Shield subscriber number, when applicable
• The date of service, when applicable
• A clear explanation of issue the provider believes to be incorrect, including supporting medical records when applicable

As applicable, Bundled Appeals must identify individually each item by using either the ICN or the section of the contract and sequential numbers that are cross-referenced to a document or spreadsheet.

Appeals that lack the required information will be returned to the provider or capitated entity.

Blue Shield will return the Appeal and notify the provider or capitated entity of the missing information necessary to research and resolve the Appeal.

The original Appeal, along with the additional information identified by Blue Shield, should be resubmitted to Blue Shield within 30 working days of the provider's receipt of the notice requesting the missing information.

Blue Shield will not require the provider to resubmit claim information or supporting documentation that has been previously received as part of the claims adjudication process.

If a contracted provider or capitated entity fails to submit an initial Appeal or final Appeal within the required timeframes, the provider or capitated entity:

• Waives the right for any remedies to pursue the matter further
• May not initiate a demand for arbitration or other legal action against Blue Shield
• May not pursue additional payment from the member

In instances where the provider's contract specifies timeframes that are greater than the timeframes stipulated in Blue Shield's Provider Appeal Resolution process, the provider's contract takes precedence.

Blue Shield will review the untimely submission of a Provider Appeal when the provider's contract includes a good cause clause for the untimely submissions of Provider Appeals.

Initial Appeals

Initial Appeals must be submitted within 365 days, or the time specified in the provider's contract, whichever is greater, of Blue Shield's date of contest, denial, notice or payment.

In the event the Appeal is regarding the lack of a decision, the Appeal must be submitted within 365 days, or the time specified in the provider's contract, whichever is greater, after the time for contesting or denying a claim has expired.

Appeals related to a demonstrable and unfair payment pattern by Blue Shield must be submitted within the timeframes indicated above, based on the date of the most recent action or inaction by Blue Shield.

Final Appeals

Final Appeals must be submitted within 65 working days of Blue Shield's Initial Appeal Determination.

Acknowledging Appeals

Blue Shield will acknowledge the receipt of each Appeal within 15 working days of the receipt of the written Appeal.

Resolving Appeals

Blue Shield will resolve Appeals within 45 working days of the receipt of the Appeal.

In the event the original Appeal was because of missing information, the amended Appeal will be resolved within 45 working days of the receipt of the resubmitted Appeal.

If the resolution of the Appeal results in additional monies due to the provider, Blue Shield will issue payment, including interest when applicable, within 5 working days of the date of the written notification.

Contesting Blue Shield's request to refund an overpayment

Providers must submit their notice contesting Blue Shield's refund request within 30 working days of the receipt of the notice of overpayment.

The provider's notice contesting Blue Shield's refund request must include the required information for submitting an Appeal as well as a clear statement indicating why the provider's believe that the claim was not overpaid.

A provider's notice that they are contesting Blue Shield's refund request will be identified as an Appeal and handled in accordance with Blue Shield's Provider Appeal Resolution Process.

Blue Shield will provide a written determination to each Appeal, stating the pertinent facts and explaining the reason(s) for the determination.

The written determination of an initial Appeal will notify providers and capitated entities of their right to file a final Appeal.

Appeals submitted on a member's behalf will be treated as a member grievance and handled within the member grievance process.

Blue Shield will verify with the member that the provider has been authorized to submit an Appeal (member grievance) on the member's behalf.

Providers or capitated entities who disagree with Blue Shield's written determination may pursue the matter further by initiating a final Appeal.

To initiate a final Appeal, providers and capitated entities must, within 65 working days of Blue Shield's initial determination, or the time specified in the provider's contract, whichever is greater, submit a written request to:
Blue Shield Final Provider Appeal and Resolution Office
       P.O. Box 629011
       El Dorado Hills, CA 95762-9011

Commercial Appeals regarding facility contract exception(s) must be submitted to:
Blue Shield Initial Appeal Resolution Office
       Attention: Hospital Exception and Transplant Team
       P.O. Box 629010
       El Dorado Hills, CA 95762-9010

The final Appeal must be submitted in accordance with the required information for an Appeal.

Blue Shield will, within 45 working days of receipt, review the final Appeal and respond in writing, stating the pertinent facts and explaining the reason(s) for the determination.

Contracted providers who disagree with Blue Shield's payment or final determination may submit the matter to binding arbitration as applicable and outlined in the provider's contract.

Provider contracts

Blue Shield informs contracting providers and capitated entities, initially upon contracting, or upon change to the Provider Appeal Resolution Process, of the procedures for submitting a provider Appeal, including:

• Identity of the office responsible for receiving and resolving provider Appeals
• Mailing address
• Telephone number
• Directions for filing an Appeal
• Directions for filing bundled Appeal
• The timeframe in which Blue Shield will acknowledge receipt of the Appeal

The disclosures are made in contracts and online beginning January 1, 2004.

Explanation of Benefits

Explanation of Benefits (EOB) inform providers of the availability of Blue Shield's Provider Appeal Resolution Process and provide instructions for filing a provider Appeal.

An EOB is sent each time Blue Shield processes a provider submitted claim. The Provider Appeal Resolution information is printed on page two of the provider's EOB.

EOBs are issued to both contracting and non-contracting providers.

Provider manuals

The Provider Appeal Resolution Process was documented beginning July 1, 2004 in the Hospital and Facility Guidelines, the Independent Physician and Provider Manual, and the HMO IPA/Medical Group Procedures Manual.

IPA/Medical Group responsibilities

In accordance with state law, IPA/Medical Groups are required to establish a fair, fast, cost-effective provider dispute resolution process.

In the event an IPA/Medical Group fails to resolve provider disputes in a timely manner, and consistent with state law, Blue Shield may assume responsibility for the administration of the IPA/Medical Group's dispute resolution mechanism.

Blue Shield contracts

Blue Shield contracts require the IPA/Medical Group to establish and maintain a fair, fast and cost-effective dispute resolution to process and resolve provider Appeals.

The IPA/Medical Group's dispute resolution process must be in accordance with sections 1371, 1371.1, 1371.2, 1371.22, 1371.35, 1371.36, 1371.37, 1371.38, 1371.4, and 1371.5 of the Health and Safety Code, and sections 1300.71, 1300.71.38, 1300.71.4 and 1300.77.4 of the CCR, title 28.

Quarterly report

IPA/Medical Groups are required to provide a tabulated report of each provider dispute received. The report must be categorized by receipt date, and include the identification of the provider, type of Appeal, disposition and work days to resolution.

Each individual Appeal in a bundled Appeal is reported separately.

Provider Appeal documentation

Upon request, the IPA/Medical Group will make available to Blue Shield, or the DMHC, all records, notes and documents regarding their provider dispute resolution mechanism and the resolution of provider Appeals.

Medical necessity denials

Blue Shield's Provider Appeal Resolution Process includes a process to allow any provider that submits a claim dispute to the IPA/Medical Group's dispute resolution mechanism involving an issue of medical necessity or utilization review an unconditional right of appeal for that claim dispute.

Provider's must submit their request to Blue Shield within 60 working days from the date they received the IPA/Medical Group determination.

Appeal

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.

Bundled Appeal

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.

Provider Inquiry

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.

Receipt Date

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.