I. Dispute Resolution Process for Professional Competence or Conduct
a.) Terminations for professional competency, conduct or quality of care
Contracted providers may dispute BCBSAZ's decision to terminate a contract for lack of professional competence or for professional misconduct.
Examples of these disputes include, but are not limited to:
- Belief that a quality-of-care issues exists
- Adverse action taken by a hospital
- Disciplinary action taken by a licensing board
- Trend or pattern of quality-of-care issues
If a provider is terminated for professional competency and/or conduct:
- BCBSAZ will notify the provider in writing of the reason for the termination
- The provider may request reconsideration in writing, not later than 30 calendar days after receipt of notice of termination from BCBSAZ.
- A reconsideration panel consisting of at least three qualified individuals, who did not participate in the original decision, with at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees, will review the reconsideration request at its next meeting (scheduled at least quarterly).
- The panel will notify the provider within 10 business days of its decision.
- If the provider is not satisfied with the panel's decision, the provider has 30 calendar days from the receipt of the decision to request a second level reconsideration (with a personal appearance before a second panel).
- A second panel of three individuals, who did not participate in the first level decision, including at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees, will hold the second level reconsideration hearing. The panel will be convened no later than 60 calendar days after the date BCBSAZ receives the provider’s request, unless an extension is necessary (for up to an additional 60 calendar days).
- The panel's decision is final and will be communicated to the provider in writing, via certified mail, within 10 business days of the decision.
b.) Immediate suspension or termination related to concerns for consumer safety
If a BCBSAZ Medical Director believes a provider is practicing in a manner that poses a significant risk to the health, welfare, or safety of consumers, BCBSAZ can either immediately suspend or terminate the provider.
- If the circumstances require an investigation for BCBSAZ to know whether the concerns are justified, BCBSAZ will immediately suspend the provider contract and conduct an expedited investigation.
- If the circumstances do not require an investigation for BCBSAZ to know whether the concerns are justified, BCBSAZ will immediately terminate the provider contract.
- Examples of circumstances that might result in immediate suspension or termination include, but are not limited to:
- Insufficient or no professional liability insurance
- Sanction by Medicare/Medicaid
- Exclusion from any Federal Programs
- A change in license status
- Fraudulent activity
When a suspension or termination occurs:
- BCBSAZ will promptly remove the provider from the directory and send the provider written notice of the action and the reason for it.
- The provider has 30 days from receipt of the notice to send BCBSAZ a written request for reconsideration if the triggering event allows for reconsideration rights (e.g. action based on certain types of felony conviction is not appealable).
If the provider is not satisfied with the panel's decision, the provider has 30 calendar days from receipt of the decision, to request a second level reconsideration (with a personal appearance before a second panel).
- A reconsideration panel will review the reconsideration request at its next meeting (scheduled at least quarterly). The panel will have at least three qualified individuals who did not participate in the original decision, with at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees.
- The panel will notify the provider of its decision within 10 business days after the meeting.
- A personal appearance panel will hold a second level reconsideration hearing no later than 60 days after BCBSAZ receipt of the request. The panel may extend the time period for up to an additional 60 days, for good cause. (The panel will have three individuals, who did not participate in the first level decision, including at least one participating provider who is a clinical peer of the requesting provider and who is not otherwise involved in BCBSAZ provider network management or other BCBSAZ committees).
- The panel's decision is final and will be communicated to the provider in writing, via certified mail, within 10 business days of the decision.
II. Dispute Resolution Process for Administrative Matters
Disputes regarding administrative matters may arise when a contracted provider wishes to protest BCBSAZ's decision that the provider has breached the provider's participation agreement, or violated a BCBSAZ policy. An administrative dispute is different from a dispute related to professional competence and/or conduct, or quality of care.
Examples of administrative disputes include, but are not limited to:
- Non-compliance with administrative terms in the network participation agreement or Provider Operating Guide.
- Billing the member improperly.
- Failure to submit requested medical records.
BCBSAZ will take appropriate action to address noncompliance. If the provider does not cure the breach, it may result in contract termination.
If BCBSAZ invokes the contractual right to terminate a provider’s contract, we will initiate the administrative dispute process as described below.
Administrative Dispute Process
- BCBSAZ will send a termination letter notifying the provider that the contract is terminated, and providing information about the dispute resolution process and reconsideration rights.
- The provider may request reconsideration in writing, no later than 30 calendar days after receipt of the notice from BCBSAZ.
- After the provider’s reconsideration request is received, an authorized representative of the organization, not involved in the initial decision on the subject of the dispute, will review the written reconsideration and make a decision.
- The authorized representative's decision is final and will be communicated to the provider in writing within 30 calendar days from the receipt of the provider's written reconsideration request.
III. Dispute Resolution Process for Provider Grievances
This dispute resolution process satisfies the Arizona state law requirement that BCBSAZ establish an internal system for resolving payment disputes and other contractual grievances with healthcare providers. It is available to contracted and non-contracted providers.
Please note: Provider grievances arising out of services rendered to Service Benefit Plan members (FEP) are not within the scope of the state law regarding provider grievances. However, the FEP program does afford providers an independent right to grieve as outlined here. FEP refers to provider grievances as provider “appeals” or “reconsiderations.”
When a provider disagrees with payment of a claim, or wishes to grieve a nonpayment issue, the provider may initiate the Provider Grievance Process (the "Grievance Process"), which has two levels of review.
Grievable issues may include but are not limited to:
- Whether a claim was clean
- Failure to timely pay a claim
- Amount paid (bundling software)
- Amount paid (other than bundling software)
- Amount or timeliness of interest payment
- Adjustment request
- Denials that require a provider write-off (for example: investigational/experimental)
- Network adequacy (other than the provider's contract status)
- Systemic or operational problems
- COB issues
- Coinsurance/deductible and sanction deductible
- Fee schedule disputes
- Outpatient global pricing
- DRG payment
- Fragmentation of incidental procedures
- Multiple medical/surgical procedure processing
- Mutually exclusive procedures
- Procedure unbundling
- Timely filing
No claim corrections are permitted once a grievance is filed.
Before submitting a grievance related to a claim, ensure that all information on the claim is accurate. A claim may not be corrected after a grievance or appeal has been filed. Grievances and appeals are carefully reviewed and decisions are based on the premise that all information on the claim is accurate.
Provider Grievance (Level 1)
All Grievances must be in writing and submitted to BCBSAZ not later than one year after the denial or other notification, or date of the occurrence if the provider did not receive notification. BCBSAZ may extend this one-year time period for good cause or if a longer period is required by state or federal law. "Good cause," as used in this section, means circumstances beyond the reasonable control of the provider, and which prevented the provider from submitting a timely grievance request.
- The provider sends a Level 1 Grievance request to BCBSAZ within the timeframe explained above, including:
- A reference to, or copy of, the action with which the provider disagrees.
- A written explanation of why the provider thinks the action is wrong, and the relief that the provider is requesting.
- All necessary documentation that supports the provider's position, such as medical records, operative reports, or office notes.
- BCBSAZ employees who were not involved in the initial determination review the grievance, including any new information submitted to BCBSAZ.
- BCBSAZ sends the provider written notice of BCBSAZ's grievance decision within 30 calendar days of receipt for pre-service issues, and within 60 calendar days of receipt for post-service issues.
BCBSAZ may extend the 30 or 60-day time period for up to an additional 60 calendar days. If BCBSAZ requires an extension, BCBSAZ notifies the provider in writing prior to the expiration of the initial time period.
BCBSAZ mails all decisions to the provider's last address on file with BCBSAZ, except for providers located outside Arizona.BCBSAZ transmits decisions for out-of-state providers to the Blue plan in the provider's home state, and that Blue plan sends the decision to the provider. The decision is deemed received on the date of delivery, if hand delivered, or, if mailed, on the earlier of the actual date of receipt or five days after deposit in the United States mail, postage prepaid.
Provider Grievance (Level 2)
If BCBSAZ's Level 1 Grievance resolution is not satisfactory, the provider may request a Level 2 Grievance. The Level 2 Grievance must be submitted in writing to BCBSAZ within 60 calendar days after receipt of the Level 1 Grievance determination. A provider may extend the 60-day time period for up to an additional 60 calendar days. If the provider requires this additional time to submit the Level 2 Grievance, the provider must notify BCBSAZ in writing within the initial 60-day period.
- The provider sends the Level 2 grievance request to BCBSAZ within the timeframe explained above, including:
BCBSAZ notifies the provider of BCBSAZ's final decision within 60 calendar days of the date BCBSAZ receives the provider's Level 2 grievance request.
- A written explanation of the reason for dissatisfaction with the prior decision
- Any additional information for review
BCBSAZ may extend this 60-day time period for up to 30 calendar days on written notice to the provider, given within the 60-day period.
Send Provider Grievances and all necessary documentation to:
BCBSAZ Appeals and Grievances Dept - Mailstop A116
P.O. Box 13466
Phoenix, AZ 85002-3466
Note: for grievances related to FEP claims or issues, use Mailstop B205
You may use the optional Provider Grievance Form [PDF].
Other information regarding grievances
- Situations not applicable to the grievance process
This provider grievance process does not apply to denial of admission to the BCBSAZ network, termination from the network, or a complaint that is the subject of a member appeal under ARS§ 20-2530.
- Appeals and grievances for members
The Provider Grievance Process is distinct from the Member Appeal and Grievance process and is not meant to limit provider participation in the Member Appeal Process. Providers who are authorized to act on behalf of a member may submit an appeal to BCBSAZ as permitted under the Member Appeal Process and applicable federal law. (Refer to Representing Member Appeals above and to the Provider Operating Guide, Section 22 for details.)
- Record requests
BCBSAZ does not request records to support a grievance. Decisions are made on the basis of the information submitted with the grievance request, in combination with records previously received.
BCBSAZ has delegated responsibility for handling grievances for certain delegated services to the vendors involved in administering those services:
Certain specialty medications and services requiring precertification through eviCore
eviCore provides precertification services for some highly specialized medications and medical services rendered as non-inpatient care, for most BCBSAZ members (see exceptions below). eviCore also processes any related first-level precertification appeals.
Submit appeal requests to eviCore as directed on the precertification denial notice. A physician who was not part of the denial decision will review the request and all clinical information provided. eviCore or BCBSAZ will mail a written notice of the appeal decision to the member and fax it to the provider.
eviCore precertification applies to most BCBSAZ-insured and –administered plans, but does not apply to:
- BCBSAZ members with PCP Coordinated Care HMO benefit plans
- Members of large, self-funded employer groups that have opted out of the eviCore program
- Federal Employee Program® (FEP®) members
- BlueCard® (out-of-area) members from other Blue plans (however, a member’s Blue plan may have its own eviCore program)
- Corporate Health Services (CHS) employee group members
Chiropractic services administered by American Specialty Health (ASH):
Chiropractic services administered by ASH for most BCBSAZ plans (see exceptions below), including administration of the dispute resolution process. Please direct disputes to ASH at this address:
American Specialty Health (ASH)
Attn: Appeals Coordinator
P.O. Box 509001
San Diego, CA 92150-9001
Phone 1 (800) 972-4226 | Fax 1 (877) 248-2746
- For disputes regarding chiropractic services provided to members of custom large groups for which ASH is not the designated administrator (and related claims), please direct the
dispute to BCBSAZ.
- For disputes regarding chiropractic services provided to FEP members (and related claims), please direct the dispute to FEP.
- For disputes regarding chiropractic services provided to out-of-area BlueCard members (and related claims), please direct the dispute to BCBSAZ.
- For disputes regarding chiropractic services provided to CHS group members (and related claims), please direct the dispute to the TPA (third party administrator).
- CHS group member appeals or provider disputes - send to the group's TPA
For CHS group members, direct all grievances to the TPA at the address listed on the remittance advice. If the grievance is related to a very specific pricing issue, the TPA will forward the grievance to BCBSAZ to review and determine if an adjustment needs to be made. If so, BCBSAZ will send the TPA a re-priced claim.