Service Standard Appeals
Physicians, physician groups, and facilities may file a Level I Provider Appeal of Blue Cross NC's application of coding and payment rules to an adjudicated claim or of Blue Cross NC's medical necessity determination related to an adjudicated claim. This notice tells you whether or not Medicare will pay for the services and how much you must pay. You may want to put your Medicare number on all your documents for redetermination and keep a copy of your request for your records. The OIG found that, of the 100 chiropractic services included in the sample, 33 were not allowable as 31 of these services were medically unnecessary and two of them were not documented.
The report from the Inspector General comes amid increasing scrutiny of Medicare Advantage organizations for potentially overcharging the government for services. You must file the request for reconsideration with the appropriate QIC within 180 days of the date you got the redetermination.
For more information on Personal Choice 65SM Medical-Only PPO's prior authorization process and what services require prior authorization, please reference Chapter 4, Section 2.1 on page 43 in your EOC or click on the link below. If we agree with our original determination, the written How to Appeal Medicare Advantage Denial notice we send will include instructions on how the enrollee can make a Level 2 appeal with the independent review organization.
Pre-service requests will be decided within a 30-day time frame, and post-service will be decided within 60 days. Some MAOs experienced no appeals while some MAOs had 40.5 percent of beneficiaries or providers appeal denied claims. If you have Original fee-for-service Medicare you have the right to appeal any decision about your Medicare services.
If you're getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare-covered services are ending too soon, you have the right to a fast track appeal.
In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt. We will make a decision regarding the appeal within 60 calendar days from the date the appeal request was received with the completed Waiver of Liability.