Representing Member Appeals

A Member Appeal is an oral or written request by a member, a provider acting on behalf of a member, or a member’s authorized representative, to challenge BCBSAZ’s decision to deny a request for precertification or a claim for services already provided.

Please Note: In some cases, BCBSAZ may be acting as an administrator for a self-funded group health plan, and not in its capacity as an insurer. References to BCBSAZ below include any delegated vendors who may process an appeal on behalf of BCBSAZ.

Issues that can be appealed or grieved
Below is a summary of those issues that can be appealed or grieved under the BCBSAZ Member Appeal and Grievance Process.

When BCBSAZ…

  • Denies a request for preauthorization of a service not yet received;
  • Denies, reduces, or terminates the member’s plan benefits;
  • Fails to provide or pay for a benefit covered under the member’s plan;
  • Finds the member ineligible for a benefit under their plan;
  • Finds the member responsible for payment of cost share (copay, deductible, coinsurance, access fee, balance bill) for a plan benefit;
  • Finds that a service is not medically necessary;
  • Finds that a service is not covered because it is experimental or investigational;
  • Determines that the member is not eligible for coverage under the benefit plan; or
  • Rescinds the member’s coverage under the plan.

Authorization to represent
Laws and benefit plans vary regarding a provider’s right to initiate an appeal on behalf of a member. For most plans, the following individuals are always authorized to appeal or grieve a decision and do not need any special authorization form:

  • The treating provider acting on the member’s behalf
  • A parent acting on the behalf of a minor

However, some plans require specific member authorization before the provider can pursue an appeal for the member. In these cases, a provider who is appealing on a member’s behalf should use the Authorized Representative Designation Form to furnish BCBSAZ with the patient’s authorization allowing the provider to receive appeal information on the patient’s behalf.

A provider initiating an appeal on behalf of a member should send the patient a copy of all information shared with BCBSAZ in connection with the appeal or grievance.

Documentation to include when submitting an appeal
To enable BCBSAZ to timely and accurately respond to an appeal, providers should include the following information:

  • A reference to the action or copy of the decision notice that is being appealed.
  • A written explanation of why the action may be incorrect, and the relief requested.
  • Documentation that disputed services meet the medical coverage guideline, pharmacy coverage guideline or commercially developed criteria such as InterQual®
  • All other documentation that supports the appeal, such as medical records, operative reports, office notes, etc.

The provider and member are responsible for sending all relevant information to support an appeal and show why BCBSAZ should change its original decision. BCBSAZ does not solicit records to support an appeal. If the provider and/or member do not provide additional documentation, BCBSAZ will decide the appeal using only the information it may already have.

BCBSAZ Member Appeal Process and Appeal Packets

BCBSAZ has a defined appeal process for members and their treating providers. However, some large, self-funded employer groups have benefit plans that require additional regulatory procedures and may have customized timelines and other protocols that deviate from the process used for most BCBSAZ members.

The specific appeals process is explained in the appeal packet which also includes all related forms that can be used. For most appeals, providers will use one of two “standard” appeals packets available below.

  1. Standard Appeal Packet 1 – for most BCBSAZ members
  2. Standard Appeal Packet 2 – for all self-funded employer groups, except those that have their own customized appeal packets (including ADOA and Teamsters).

For help in determining which appeal packet to use for a particular member, call:
Medical Appeals and Grievance Department
Phone: (602) 544-4938 or 1 (866) 595-5998

Expedited Appeals
Expedited appeals require the treating provider to certify orally or in writing that the time periods required to process standard appeals could seriously jeopardize the member’s life, health or ability to regain maximum function, cause a significant negative change in the member’s medical condition at issue, or subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

See the expedited appeal form below.

Exceptions
The BCBSAZ Member Appeal process does not apply to:

  • Members of other Blue Cross and Blue Shield plans - other Blue plans have their own appeals procedures.
  • Participants in a self-insured plan that customizes its appeal procedures.
  • Enrollees in the Federal Employee Program (FEP) - providers cannot appeal an FEP claim denial unless they are appealing on the member’s behalf with signed consent from the member. For details, refer to the Service Benefit Plan Brochure (RI-71-005) online at fepblue.org. For provider disputes regarding adverse benefit determinations, refer to the Provider Dispute Resolution Processes below.
  • Provider grievances - refer to the Provider Dispute Resolution Process below related to provider grievances or other administrative complaints.

BCBSAZ delegates responsibility for appeals of some benefits to other vendors. Those vendors are also identified in the Standard Appeals Packets below.

For more information about the BCBSAZ Member Appeals and Grievances Process, please refer to the Standard Appeal Packets below and the BCBSAZ Provider Operating Guide, Section 22.

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Provider Dispute Resolution Processes

BCBSAZ provider dispute resolution processes apply to:

  1. Disputes concerning a provider's professional competence or conduct (Credentialing Disputes) - this process is available to professional and facility providers credentialed by BCBSAZ and holding a Provider Participation Agreement with BCBSAZ.
    1. Terminations for professional competency and/or conduct, or quality-of-care issues
    2. Immediate suspension or termination for concerns for consumer safety
  2. Disputes involving administrative matters not related to quality of care (Administrative Disputes).

  3. Disputes regarding adverse claim determinations, payment disputes, timely filing, systemic or operational problems (Provider Grievances).

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:

  1. BCBSAZ will notify the provider in writing of the reason for the termination

  2. The provider may request reconsideration in writing, not later than 30 calendar days after receipt of notice of termination from BCBSAZ.

    2a. 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).

    2b. The panel will notify the provider within 10 business days of its decision.

  3. 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).

    3a. 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).

    3b. 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:

    1. The provider will promptly be removed from the provider directory.

    2. BCBSAZ will notify the provider in writing of the reason for the suspension or termination

    3. The provider may request reconsideration in writing, not later than 30 calendar days after receipt of notice from BCBSAZ of the suspension or termination. Not all termination events allow for reconsideration rights (e.g. conviction pertaining to felony).

      3a. 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).

      3b. The panel will notify the provider within 10 business days of the decision.

    4. 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).

      4a. 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).

      4b. 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

Administrative Disputes

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 participation agreement or Provider Operating Guide.
  • Billing the member improperly.
  • Failure to submit requested medical records.

BCBSAZ sends out a notice of breach letter to advise the provider of the objectionable conduct and request that the provider comply. If the provider fails to cure the breach within the stated timeframe (typically 30 calendar days), BCBSAZ will initiate the administrative dispute process (see below).

Administrative Dispute Process

  1. To begin the process, BCBSAZ will send a termination letter notifying the provider that the contract is terminated, and providing information about the reconsideration rights.

  2. The provider may request reconsideration in writing, no later than 30 calendar days after receipt of the notice from BCBSAZ.

  3. 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.

  4. 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 is intended to satisfy the requirements of Arizona state law that requires 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
  • Modifiers
  • 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.

  1. 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.
  2. BCBSAZ employees who were not involved in the initial determination review the grievance, including any new information submitted to BCBSAZ.

  3. 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.

  1. The provider sends the Level 2 grievance request to BCBSAZ within the timeframe explained above, including:
    • A written explanation of the reason for dissatisfaction with the prior decision
    • Any additional information for review
  2. 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.

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

You may use the optional Provider Grievance Form [PDF].

Other information regarding grievances

  • 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.
  • The Provider Grievance Process is distinct from the Member Appeal and Grievance process and is not intended 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 administering those services:

1. Chiropractic Services

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

Exceptions:

  • 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 that are not related to claims pricing

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.

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