For Providers: How Do I Appeal a Medicare Payment or Claim?

Contracted providers with Blue Cross’ Medicare Advantage PPO have their own appeals rights. Providers may appeal decisions on denied claims, such as denial of a service related to medical necessity and appropriateness. 

Providers may also dispute a payment made to them by the Medicare Advantage PPO plan that is less than the payment amount that would have been paid under the Medicare fee schedule. Blue Cross' Medicare Advantage PPO providers should follow the guidelines on this page when submitting an appeal.

Michigan providers can either call or write to make an appeal or file a payment dispute. Call 1-866-309-1719 or write to us using the following address:

Medicare Plus Blue 
Provider Inquiry
P.O. Box 33842
Detroit, MI 48232-5842

If you are a dentist, write to us and send to the address listed below for dental providers. 

What to include in your written request for a claim denial appeal or payment dispute

First-level appeal 

Initial appeal requests for a claim denial must be submitted within 60 days from the date the provider receives the initial denial notice. Be sure to include the following information with your written appeal:

  • Provider or supplier contact information including name and address 
  • Reason for dispute; a description of the specific issue
  • Copy of the provider’s submitted claim with disputed portion identified
  • Copy of the plan’s original claim determination
  • Documentation and any correspondence that supports your position that the plan’s original claim determination was incorrect, including any applicable medical notes and/or medical records (history, physical and operative notes, etc.), Medicare guidance, NCD or LCD when appropriate
  • Appointment of provider or supplier representative authorization statement, if applicable
  • Name and signature of the provider or provider’s representative

Second-level appeal 

If you believe that we have reached an incorrect decision regarding your first-level appeal, you may file a request for a secondary review of this determination. A request for secondary review must be submitted in writing within 60 days of written notice of the first-level decision from Medicare Plus Blue. Decisions from this secondary review will be final and binding. Be sure to include the following information with your written appeal:

  • Provider or supplier contact information including name and address
  • Reason for dispute; a description of the specific issue
  • Copy of the provider’s submitted claim with disputed portion identified
  • Copy of the plan’s original claim determination
  • Documentation and any correspondence that supports your position that the plan’s first-level appeal review claim determination was incorrect, including any applicable medical notes and/or medical records (history, physical and operative notes, etc.), Medicare guidance, NCD or LCD when appropriate
  • Appointment of provider or supplier representative authorization statement, if applicable
  • Name and signature of the provider or provider’s representative
  • Copy of the first-level appeal response letter

First-level dispute

Payments must be disputed within 120 days from the date payment is initially received. We will review your dispute and respond to you within 60 days from the time we receive notice of your dispute. If we agree with your position, then we will pay you the correct amount. We will inform you in writing if your payment dispute is denied. Be sure to include the following information with your written request:

  • Provider or supplier contact information including name and address
  • Reason for dispute; a description of the specific issue
  • Copy of the provider’s submitted claim with disputed portion identified
  • Copy of the plan’s original pricing determination
  • Documentation and any correspondence that supports your position that the plan’s original reimbursement was incorrect (including interim rate letters when appropriate, pricer screen prints, etc.)
  • Appointment of provider or supplier representative authorization statement, if applicable
  • Name and signature of the provider or provider’s representative

Second- level dispute

If you still believe that we have reached an incorrect decision regarding your payment dispute, you may file a request in writing for a secondary review of this determination within 60 days of receiving written notice of our first level decision. To request a secondary review of this determination, write to:

Medicare Advantage PRS – Appeals
Attn: Second Level Payment Dispute Blue Cross
P.O. Box 441160
Detroit, MI 48244-1160

We will review your dispute and respond within 60 days of the date on which we received your request for a secondary review. Decisions from this secondary review will be final and binding. Be sure to include the following information with your written request:
  • Provider or supplier contact information including name and address
  • Reason for dispute; a description of the specific issue
  • Copy of the provider’s submitted claim with disputed portion identified
  • Copy of the plan’s original pricing determination
  • Copy of the plan’s first-level dispute pricing decision letter
  • Documentation and any correspondence that supports your position that the plan’s first-level reimbursement review was incorrect (including interim rate letters when Slappropriate, pricer screen prints, etc.)
  • Appointment of provider or supplier representative authorization statement, if applicable
  • Name and signature of the provider or provider’s representative

First-level dispute 

Write to the following address:

Medicare Advantage
Blue Cross Blue Shield of Michigan
P.O. Box 49
Detroit, MI 48231

Second-level dispute

If you disagree with the decision made on your first appeal, you may request a managerial level review conference within 60 days of receiving the original decision. The address to request your managerial level review conference is:

Medicare Advantage Dental Provider Grievances & Appeals (second level)
600 E. Lafayette – Mail Code 517K
Detroit, MI 48226

Be sure to include the following information with your request for a secondary review:

  • Provider or supplier contact information including name and address
  • Pricing information, including NPI number (and CCN or OSCAR number for institutional providers), ZIP code where services were rendered, and physician specialty
  • Reason for dispute; a description of the specific issue
  • Copy of the provider’s submitted claim with disputed portion identified
  • Copy of the plan’s original pricing determination
  • Copy of the plan’s first-level dispute pricing decision letter
  • Documentation and any correspondence that supports your position that the plan’s first-level reimbursement review was incorrect (including interim rate letters when appropriate)
  • Appointment of provider or supplier representative authorization statement, if applicable
  • Name and signature of the provider or provider’s representative

 

For retroactive audit disputes, the appeals process contains the following steps:

1. Internal Review: You may submit a written request that documents the cases being appealed for an internal review within 50 days of receiving our audit determination. You may also submit additional information to support your position. Within 50 calendar days of receiving your request, we will send you our determination. You may further appeal this determination by requesting an external appeal


2. External Peer Review: You may submit a written request that documents the cases being appealed for an external peer review within 20 days of receipt of our internal review determination. Only previously submitted information will be used for this review. Within 50 calendar days after your submission of medical records, the review organization communicates its determination, which is binding for both of us. If our decision is upheld, you pay the review cost. If our decision is reversed, then we absorb the cost. If our findings are partially upheld and partially reversed, we share the review cost with you in proportion to the results. This ends the appeal process.

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