FAQs

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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.