Note: Not all states allow providers to initiate an appeal/grievance on behalf of a member. In these cases, a provider who is appealing on a member’s behalf should use the Authorized Representative Designation Form to send us the patient’s authorization allowing the provider to receive appeal information on the patient’s behalf.Ī provider initiating an appeal on behalf of a member should send the patient a copy of all information shared with us in connection with the appeal or grievance. However, a few BCBSAZ plans for self-funded groups require specific member authorization before the provider can pursue an appeal for the member. A parent acting on the behalf of a minor.The treating provider acting on the member’s behalf.For most BCBSAZ plans, the following individuals are always authorized to appeal or grieve a decision and do not need any special authorization form: Laws and benefit plans vary regarding a provider’s right to initiate an appeal/grievance on behalf of a member. Rescinds the member’s coverage under the plan.Determines that the member is not eligible for coverage under the benefit plan.Finds that a service is not covered because it is experimental or investigational.Finds that a service is not medically necessary.Finds the member responsible for payment of cost share (copay, deductible, coinsurance, access fee, balance bill) for a plan benefit.Finds the member ineligible for a benefit under his or her plan.Fails to provide or pay for a benefit covered under the member’s plan.Denies, reduces, or terminates the member’s plan benefits.Denies a claim for services already received.Denies a request for preauthorization of a service not yet received.Refer to the Federal plan brochure for more information.Below is a summary of those issues that can be appealed or grieved through our member appeal and grievance process. For HMSA’s Plan for Federal Employees, claims will be accepted until December 31 of the year after the year service was received. Note: Claims must be received within a year from the last day on which services were received. A brief description of the service and/or why the service was needed.A daytime phone number where you can be reached.The name, date of birth, address, and HMSA membership number of the person that received the service or supply.Please include a cover letter with the documents you submit. Information about other health coverage you may have.Where the service was received (for example, an office, outpatient clinic, or hospital).Diagnosis or type of illness or injury.currency at the exchange rate on the date of service. Cost for services that are listed in a foreign currency will be converted to U.S. Date(s) of the injury or start of illness.
BLUE CROSS TIMELY FILING FULL
The provider statement must include all of the information below: We require a provider statement in order to process your claim for services. Please keep the originals for your records, because documents you submit to HMSA won’t be returned to you. Submitting your request for reimbursementĬopies of the provider statement and any supporting documents you send to HMSA should be clear and legible, with your HMSA subscriber number written on each page. Note: For information on Medicare claims, please refer to the articles Senior Connection Plan Certificate or HMSA Akamai Advantage Evidence of Coverage. Submit the claim to HMSA at the appropriate address. Just send HMSA the statement prepared by your nonparticipating or out-of-state provider and make sure the statement includes all of the information listed below.įor timely claims processing, please submit your claim within a year from the last day on which you received services.
If your nonparticipating provider in Hawaii or an out-of-state provider doesn’t file for you, you can submit a claim to us for payment.
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