Utilization Management Appeals - bcbs

A Utilization Management (UM) Appeal is defined as a written request from a provider to review a claim that required an authorization or precertification affecting a claim’s payment. This does not include provider appeals of pre-service determinations (unless required under ERISA), claims status requests, telephone inquiries or post-service claims review regarding the application of benefits or allowed amounts.

UM appeals must be filed pursuant to the timeliness requirements of the applicable Agreement with BCBSF or within five years from payment date. BCBSF will not overturn administrative claim denials based on the provider’s failure to comply with required procedures and time frames. UM appeals should be sent to the address below with the following information:

• The completed Provider Appeal Form (available at www.bcbsfl.com).

• A copy of the remittance advice.

• The necessary medical documentation (e.g., operative report, physician orders, etc.) as indicated by the reason for the reduction or the denial on the remittance advice.

Send UM appeals to:

Blue Cross and Blue Shield of Florida

Provider Disputes Department

P.O. Box 43237

Jacksonville, FL 32203-3237

Note: For information on the appeal of pre-service and concurrent review decisions refer to the Utilization Management Programs section.