Filing an appeal

Quick reference guide

Providers and members (and member-authorized representatives) have appeal rights.

Appeal rights allow an individual to officially respond to 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.

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).

Processes for providers to follow:

  • Utilize the peer-to-peer option before submitting an appeal (800.471.2242, option 2).
  • Provide a completed provider dispute form located in the provider library for provider-specific appeals.
  • Include completed ADAR form located in the provider library with appeals submitted on behalf of the member. Provider dispute form is not required.
  • Include a physician statement when requesting an expedited review (required). The statement must provide justification that expedited processing required to avoid serious harm to the member along with an explanation as to why item/service to be reviewed urgently.
  • 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.
  • Submit all appeals via established processes:
    • Mail or fax for post-service provider appeals.
    • Mail, fax, or phone call (to member services) for pre-service appeals on behalf of the member(s).

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.

Contact and appeal submission information

To fax an appeal request:

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

To mail an appeal request:

Capital Blue Cross Appeals and Grievances

Resolution Unit
PO Box 779518
Harrisburg, PA 17177-9518