FEATURE story FILING WELLPOINT APPEALS WHAT YOU NEED TO KNOW By Kimberly Stevens An appeal (also known as a grievance by some insurance regulators) is a formal request for a health plan to look at an adverse coverage decision. Two types of appeals exist within the industry: member and provider appeals. • a member appeal is a formal request for review of a prospective, concurrent, or retrospective adverse coverage decision. a member – or their authorized representative, who may be you or any other person they choose – may ask for a member appeal. • a provider appeal is a formal request for review of a provider contractual or reimbursement issue or retrospective adverse coverage decision. a provider is the only one who can appeal on his or her own behalf. Please note that most health plans only offer one level of review for provider appeals. therefore, it is usually better to work with the plan’s contract manager prior to asking for an appeal in order to preserve appeal rights. most health plans require that a provider request appeals in writing. however, depending on state regulatory requirements, you may have the option to ask for a member appeal by phone. many health plans will also have the option to ask for an appeal online. if you go to the health plan’s website, you will be able to read about the appeals process and will be provided with a link to forms, if available. the following is a list of our health plans’ websites: anthem blue cross and blue shield . . . . . . . . . . . . . www.anthem.com anthem blue cross. . . . . . . . . . . . . . . . . . . . . . . . . www.anthem.com/ca blue cross blue shield of georgia . . . . . . . . . . . . . . . www.bcbsga.com empire blue cross blue shield. . . . . . . . . . . . . . . www.empireblue.com health link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.healthlink.com unicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . www.unicare.com in order to ensure a timely and appropriate resolution of your appeal, it is important that you do not combine your request for an appeal with any other issues, such as: • claims corrections • claims issues where the plan has requested additional information • 151s (specific to Virginia) • accounts receivable inquires • requests to trace a check • any other request that does not meet the appeal definitions above We further suggest that you: • use an appeal request form, if available • include the word APPEAL in bold in your request • include (if available) the patient’s name, identification number, date(s) of service, claim number(s), and the plan’s case number • provide the specific reason(s) for the appeal • include all relevant information, such as medical records or other supporting documentation, regardless of whether it was considered at the time the initial decision was made • include proof of timely filing, if applicable it is important for you to explain to the plan exactly why you feel that each claim that you wish to appeal should be reconsidered. giving a generic reason for the appeal will make it difficult for Wellpoint to respond timely and appropriately. Appeals for Claim Timely Filing claim timely filing appeals tend to be one of the highest-ranking contractual appeals we receive from providers. in california alone, claim timely filing appeals rank as the third highest contractual appeal category received from providers in 2012. timely filing appeals represent 2.67 appeals per thousand members per year. to help us process claim timely filing appeals, please remember to send us proof that you filed your claim(s) timely. the following are acceptable forms of proof of claim timely filing (see figure 1): the journal of the healthcare billing and management association 31
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