MEDICAL APPEALS
Medical Appeals are clinical in nature and involve adverse benefit determinations of not medically necessary or investigational. All other Appeals are considered Administrative Appeals and are handled by the Administrative Appeals and Grievance Department. The process and contact information for this department is located elsewhere in this document.
We recognize that disputes may arise between members (member’s provider) and Blue Cross regarding covered services. An appeal is a written request from the member or authorized representative to change a prior decision that Blue Cross has made about covered services. Examples of issues that qualify as appeals include denied authorizations, claims based on adverse determinations of medical necessity or investigational denials, and be nefit determinations. A rescission of coverage is also eligible for an appeal.
The Member has the right to appoint an authorized representative to speak on their behalf in their Appeals. An authorized representative is a person to whom the Member has given written consent to represent the Member in an internal or external review of a denial. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.
The Member, their authorized representative, or a Provider authorized to act on the Member’s behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Requests submitted to Us after one hundred eighty (180) days of Our initial determination will not be considered.
Member appeals processes vary due to variations in state and federal laws. We will apply the law that governs the benefits purchased by the member or the member’s employer. In some instances this is state law, and in others, it is federal law. The member’s contract or certificate describes the appeals processes applicable to the member. We will follow the language in the member’s contract or certificate, should there be any variance between that language and what is printed below.
Due to variations between federal and state laws, appeals for ERISA members are handled differently from non-ERISA member appeals. There are some plans that are not governed by either the state laws or the ERISA laws. Examples are some plans for whom we provide administrative services only and the Federal Employee Program. For these members, we will follow the appeals processes stated in their member contracts. The majority of appeals should fall within the ERISA or non-ERISA (state) processes. If members are unsure which process applies to them, they should contact their employer, Plan Administrator, Plan Sponsor or Blue Cross at 1-800-599-2583 or 225-291-5370. Members and providers are encouraged to provide Blue Cross with all available information and documentation at the time of the appeal request to help Us completely evaluate the appeal.
Louisiana laws apply to individual contracts of insurance, employer insurance plans that are not governed by ERISA, and non-federal government insurance plans. Blue Cross generally refers to these processes as “Non-ERISA” processes. We will follow internal and external laws set out in La. R.S. 22:2391 et seq. and applicable regulations for these types of plans. We will follow the appeal rules for ERISA plans as set out in 29 CFR 2560 et seq. If the laws that affect appeals for any type of plan change, we will revise our process to maintain compliance.
We will investigate the Member’s concerns. If we change Our original decision at the first level, We will process the Member’s Claim and notify the Member and all appropriate Providers. If the original determination on the Member’s Claim is upheld, We will notify the Member and all appropriate Providers of the decision. Notice of the Administrative Appeal decision will be sent in writing within thirty (30) calendar days of our receipt of the member’s request; unless it is mutually agreed that an extension of the time is warranted.
Both federal and state Medical Appeals processes include two levels of review; an internal level and an external level.
The internal level of review will be conducted by Persons not involved in previous decisions regarding the member’s claim will decide all Appeals. A physician or other health care professional; in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review and who is not subordinate to any previous decision-maker on the member’s claim, will review medical necessity appeals.
External level of review can be requested by the member, their authorized representative, or a provider authorized to act on the member’s behalf, who must submit a written request to Appeal within one hundred twenty (120) days following the member’s receipt of an internal appeal adverse benefit determination. Request submitted to us after one hundred twenty (120) days of Our internal appeal determination will not be considered. Please note that for those plans subject to Louisiana state law, the External Review request form provided with an internal appeal denial notice MUST be signed by the member and returned with any request for External Review.
The external level of review will be conducted by a non-affiliated Independent Review Organization (IRO). We will provide the IRO all pertinent information necessary to conduct the Appeal. The IRO decision will be considered a final and binding decision on both the Member and Us.
The external review will be completed within forty-five (45) days of Our receipt of the request, and the IRO will notify the Member or their authorized representative and all appropriate Providers of its decision.
Expedited Medical appeals requests are available in cases where review of an Adverse Determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the member may experience pain that cannot be adequately controlled while awaiting a standard internal appeal decision. In these cases, we will make a decision no later than seventy-two (72) hours of our receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal.
An Expedited Appeal is a request concerning an Admission, availability of care, continued stay, or health care service for a covered person who is requesting Emergency services or has received Emergency services, but has not been discharged from a facility. Expedited Appeals are not provided for review of services previously rendered. An Expedited Appeal shall be made available to, and may be initiated by the covered person; the covered person’s authorized representative, or the Provider acting on behalf of the covered person.
Standard Administrative Appeal
First Level Administrative Process
Administrative Appeals involve contractual issues other than Medical Necessity or Investigational denials and those denials that do not require medical judgment.
If the Member is not satisfied with Our denial of services, the Member, their authorized representative, or a Provider acting on their behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Appeals should be submitted in writing to:
Medical Benefits:
Blue Cross and Blue Shield of Louisiana
Appeals and Grievance Unit
P. O. Box 98045
Baton Rouge, LA 70898-9045
Pediatric Dental Care Benefits: (applicable to Non-Grandfathered Individual and Small Group ONLY)
Blue Cross and Blue Shield of Louisiana
Dental Customer Service
P. O. Box 69420
Harrisburg, PA 17106-9420
Pediatric Vision Care Benefits: (applicable to Non-Grandfathered Individual and Small Group ONLY)
Blue Cross and Blue Shield of Louisiana
c/o Davis Vision
P. O. Box 791
Latham, NY 12110
Note: Requests submitted to Blue Cross after one hundred eighty (180) days of the denial will not be considered.
We will investigate the Member’s concerns. If We change Our original decision at the Appeal level, We will process the Member’s Claim and notify the Member and all appropriate Providers, in writing, of the first level Appeal decision. If the Member’s Claim is denied on Appeal, We will notify the Member and all appropriate Providers, in writing, of Our decision within thirty (30) calendar days of the Member’s request; unless We mutually agree that an extension of the time is warranted. At that time, We will inform the Member of the right to begin the second level Appeal process, if applicable.
Second Level Administrative Process (If Applicable)
Within sixty (60) calendar days of the date of Our first level Appeal decision, a Member who is not satisfied with the decision may initiate, with assistance from the Customer Service Unit, if necessary, the second level of Appeal process. Requests submitted to Us after sixty (60) days of the denial will not be considered.
A Member Appeals Committee not involved in any previous denial will review all second level Appeals. The Committee’s decision is final and binding as to any administrative Appeal and will be mailed to the Member within five (5) days of the Committee meeting.
Standard Medical Appeal
Internal Process
Medical Appeals involving a denial or partial denial based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational. If the Member is not satisfied with Our denial of services, the Member, their authorized representative, or a Provider acting on their behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Appeals should be submitted in writing to or fax to:
Blue Cross and Blue Shield of Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837
HMO Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837
Note: Requests submitted to Blue Cross after one hundred eighty (180) days of the denial will not be considered.
We will investigate the member’s concerns. All Appeals of Medical Necessity denials will be reviewed by a physician or other health care professional in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review. If our initial denial is overturned on the Member’s Medical Necessity Appeal, We will process the claim and will notify the Member and all appropriate Providers, in writing, of the Internal Appeal decision. If our initial denial is upheld, We will notify the Member and all appropriate Providers, in writing, of our decision and advise the Member of their right to request an External Appeal. The decision will be mailed within thirty (30) days of the member’s request, unless the member or their authorized representative and We mutually agree that an extension of the time is warranted. At that time, We will inform the member of their right to begin the External Appeal process if the claim meets the criteria.
External Process
If the Member still disagrees with our determination on their Claim following the internal review process, the Member or their authorized representative may request an External Appeal conducted by a non-affiliated Independent Review Organization (IRO). The Member must send their written request for an external Appeal, within one hundred twenty (120) days* of receipt of the Internal Appeal decision.The Member must grant permission for the request of an External Review by completing and submitting at the time of External Appeal request the form "I want to ask for an External Appeal." Any external review requested without the required form will not be considered.
Blue Cross and Blue Shield of Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837
HMO Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax 225-298-1837
We will provide the IRO all pertinent information necessary to conduct the Appeal. The IRO decision will be considered a final and binding decision on both the Member and Us. The external review will be completed within forty-five (45) days of Our receipt of the request and the IRO will notify the Member or their authorized representative and all appropriate Providers of its decision.
* Requests submitted to us after one hundred twenty (120) days of receipt of the internal Appeal decision will not be considered.
Expedited Appeals
Internal Process
We provide an Expedited Appeal process for review of an Adverse Determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the Member may experience pain that cannot be adequately controlled while awaiting a standard Internal Appeal decision.
The Expedited Appeal process allows for expedited appeal decisions no later than seventy-two (72) hours of our receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal.
An Expedited Appeal is a request for immediate review of an initial non-certification determination concerning an admission, availability of care, continued stay, or health care service for a covered person or his authorized representative who is requesting emergency services or has received emergency services but has not been discharged from a facility or if waiting for the standard appeal 30 day process could seriously jeopardize the member’s life, health or ability to regain maximum function or in the treating physician’s opinion, the patient would be subjected to severe pain without care or treatment. Expedited Appeals are not provided for services previously rendered.
Blue Cross and Blue Shield of Louisiana, Inc.
Expedited Appeal - Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837
HMO Louisiana, Inc.
Expedited Appeal - Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
In any case where the Expedited Internal Appeal process does not resolve a difference of opinion between Us and the covered person or the Provider acting on behalf of the covered person, the Appeal may be elevated to an Expedited External Appeal.
External Process
An Expedited External Appeal of an adverse decision is available when requested by the Member, their authorized representative or a provider acting on behalf of a member.
An Expedited External Appeal is a request for immediate review of an initial non-certification determination concerning an admission, availability of care, continued stay, or health care service for a covered person or his authorized representative who is requesting emergency services or has received emergency services but has not been discharged from a facility or if waiting for the standard Appeal 30 day process could seriously jeopardize the member’s life, health or ability to regain maximum function or in the treating physician’s opinion, the patient would be subjected to severe pain without care or treatment.
Expedited External Appeals are not provided for review of services previously rendered. An Expedited External Appeal is also available if the Adverse Determination involves a denial of coverage based on a determination that the recommended or requested health care service or
treatment is deemed Investigational; and the covered person’s treating Physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the Adverse Determination would be significantly less effective if not promptly initiated. The request may be simultaneously filed with a request for an expedited internal review, since the Independent Review Organization assigned to conduct the expedited external review will determine whether the request is eligible for an external review at the time of receipt.
We will forward all pertinent information for Expedited External Appeal requests to the IRO so the review may be completed within seventy-two (72) hours of receipt.
All external review decisions are binding on Us and You for purposes of determining coverage under a health Contract. This Appeals process shall constitute Your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary, except to the extent that other remedies are available under state or federal law.
Please Note:
Although submission of additional information is not required at the time an appeal request is requested, an explanation and/or supporting documentation for an appeal is recommended.
Dispute Resolution
Blue Cross has established a general dispute resolution process to resolve any problems and disputes concerning Blue Cross’ right of offset or recoupment. To initiate the general dispute resolution process, providers should send a written notice with a brief description of their dispute to:
Blue Cross and Blue Shield of Louisiana
Provider Dispute
P.O. Box 98021
Baton Rouge, LA 70898-9021
Within sixty (60) calendar days of our receipt of the provider’s notice, Blue Cross and the provider will assign appropriate staff members who are to arrange to discuss and seek resolution of the dispute, consistent with the terms of the provider’s agreement with Blue Cross. Any and all dispute resolution procedures are to be conducted only between Blue Cross and the provider and shall not include any Blue Cross or HMO Louisiana member unless such involvement is necessary to the resolution of the dispute. Blue Cross, in its sole discretion, will determine if the member’s involvement is necessary to the resolution of the dispute.
If Blue Cross and the provider are unable to reach resolution within the initial sixty (60) day period, then management from both Blue Cross and the provider, who were not involved in the initial discussion, will have an additional thirty (30) days to resolve the dispute. This time period may be extended by mutual agreement between Blue Cross and the provider. Blue Cross and the provider, as mutually agreed, may include a mediator in such discussions. Blue Cross and the provider shall share the costs of the mediation equally. In any event, if additional meetings are held and no resolution of the dispute is reached within sixty (60) days from the initial meeting, Blue Cross and the provider shall elect binding arbitration as described in the Arbitration section below in order to resolve the dispute. Blue Cross or the provider’s failure to participate in the arbitration proceedings means that they have accepted the other’s demands. If resolution of the dispute occurs, Blue Cross and the provider shall express the resolution in written form or amend the provider’s agreement to include the resolution, if appropriate.
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