FAQs
Complaints & Appeals
What is the procedure for lodging
a complaint against a provider?
How do I appeal a certification
or authorization denial?
How do I appeal a claim payment
or denial?
What if waiting for you to
decide on my appeal would harm my health?
My Explanation of Benefits
says I received services that I did not have. What should
I do?
Q: What is the procedure
for lodging a complaint against a provider?
A: If you have a complaint regarding a
provider, please contact Customer Service at 1-800-914-4220.
The complaint will then be researched and handled appropriately.
Q: How do I appeal
a certification or authorization denial?
A: You have the right to request a formal
appeal of a denial of benefit coverage. A detailed description
of this process may be found in your Member Guide. Customer
Service can also assist you in starting the appeal process.
BCBSNC will work with you to resolve the issue. For each
step in the appeals process, there are specified time frames
for filing a grievance and for BCBSNC to notify you or your
provider of the decision.
Q: How do I appeal
a claim payment or denial?
A: You have the right to request a formal
appeal of the claim payment or denial. A detailed description
of this process may be found in your Member Guide. Customer
Service can also assist you in starting the appeal process.
BCBSNC will work with you to resolve the issue. For each
step in the appeals process, there are specified time frames
for filing a grievance and for BCBSNC to notify you or your
provider of the decision.
Q: What if waiting
for you to decide on my appeal would harm my health?
A: You have the right to request a more
rapid or expedited review of a denial of coverage if a delay
would reasonably appear to seriously jeopardize you or your
dependent's life, health or ability to regain maximum function.
An expedited review may be requested by calling Customer
Service at 1-800-914-4220. BCBSNC will communicate the decision
by phone to you and your provider as soon as possible, but
no later than 72 hours after receiving the request for the
expedited appeal. A written decision will be communicated
within four days after receiving the request for the expedited
appeal.
Q: My Explanation
of Benefits says I received services that I did not have.
What should I do?
A: Please notify BCBSNC as soon as possible
by contacting Customer Service at 1-800-914-4220.
