Filing an appeal

Quick reference guide

Providers and members (and member-authorized representatives) have appeal rights, allowing them to officially dispute a denial and/or payment of services. This quick reference guide has been created to assist providers in navigating the appeals process and provide a clear and efficient explanation of the requirements.

Important Reminder: Prior to filing an appeal, providers are encouraged to utilize the peer-to-peer option by calling 800.471.2242

Providers are entitled to:

  • 1st internal level of appeal.
  • 2nd level independent review appeal after a 1st internal appeal is completed, resulting in continued denial of requested services and/or claim payment. Please note, provider payment is required for this review. (Refer to the provider manual for requirements that must be met by the provider when submitting 2nd level independent review requests.)

Providers may:

  • Submit an internal 1st level appeal for claim denials. Provider dispute form is required with all appeals.
  • Submit pre-service appeals on behalf of a member (ADAR form required).
  • Submit an expedited pre-service appeal request for a member if all required documentation is included in the appeal submission.

Providers may also access the following available resources to locate policies, appeals, preauthorization information, peer-to-peer physician contact information, and forms. For preauthorization, peer-to-peer physician reviews, and clinical management, call 800.471.2242, option 2.  For more information on Availity® provider portal call 800.AVAILITY (800.282.4548).

Appeal Process for Providers

  • Provide a completed Claim Appeal Form located on Capital’s provider page for provider-specific appeals. If an appeal is being filed on behalf of a member, include an Authorization of Designated Appeals Representative (ADAR) form.
  • Provide all applicable medical records/documentation to support the appeal request and address the stated denial reason that is being appealed.
  • Include all provider contact information including fax number, office number, and address.
  • Include all member information including full name, date of birth, and address.

Expedited Appeal Reviews:

Member may request an expedited review if any of the following situations apply:

  • Member has a medical condition for which the time frame for completion of a standard external review would seriously jeopardize their life or health or would jeopardize their ability to regain maximum function.
  • The denial concerns an admission, availability of care, or continued stay or healthcare service for which they received emergency services but have not been discharged from the facility in which they received emergency services.
  • The denial is based on a determination that the recommended or requested healthcare services are experimental or investigational and the treating healthcare provider certifies in writing that the recommended or requested healthcare services would be significantly less effective if not promptly initiated.

Appeal notes

  • Pre-service appeals: Processing timeframe is 30 days.
  • Expedited pre-service appeals that meet the expedited criteria: Processing timeframe is 72 hours.
  • Post-service appeals: Processing timeframe is 60 days.
  • Appeals process are not started until all necessary documentation is received.
  • Missing documents/information will delay the start of processing of an appeal.

Medicare Advantage plans

Prior to making a decision, the medical director will outreach to the provider to ensure all clinical information is received to make the determination. Additional information can be provided at that time prior to the decision being made.

If a service is denied by the medical director, the provider can still request a phone call with the medical director, but the denied service cannot be overturned. The provider must go through the appeals process.

For member calls, please refer members to member services. The medical director will not have a peer-to-peer discussion with the member. The member will need to start an appeal with member services.

Appeals Submission Information

Electronic Submission

Submit appeals and upload supporting medical records and documentation through Capital’s provider portal, Availity Essentials

To help providers navigate this process, online training is available through the Availity platform. To access the training:

  1. Log in to Availity Essentials.
  2. Select Help and Training in the upper-right corner.
  3. Click Get Trained.
  4. Select Catalog.
  5. Search for "Appeals".
  6. Open Availity Appeals Training Demo and select the Non-Payer Specific course.

Fax

Medicare products
  • Capital Blue Cross Appeals and Grievances Resolution Unit, Medicare Advantage 888.456.2449
Commercial products
  • Capital Blue Cross Appeals and Grievances Resolution Unit, Commercial 717.541.6915

Mail

Capital Blue Cross Appeals and Grievances
Resolution Unit
PO Box 779518
Harrisburg, PA 17177-9518