03/21/2017
Excellus BCBS-Appeal Rights/Clinical Editing Review Request Form
Can you explain to me why we have no more appeal rights after a "clinical editing" decision... I spoke to my rep this morning about a clinical edit denial (which I didn't even send to - it was just a claim adjustment , changing some modifiers) of a claim that had the correct modifiers on it... she told me there is no way of changing their decision and that I have no further appeal... we are having a terrible time getting them to pay for a lot of things , including our diabetics ... seems like I am fighting for every dollar.... always seems to be the Medicare Blue Choice patients who are affected and it's when multiple procedures are done.. they have their edits in there that kick everything out and I have to send everything back and now they are starting to deny those too... help!
No appeal rights were given by Excellus BC/BS because the incorrect form was used to request a review of the bundled services. As per the insurance’s provider manual, there is a separate form used (see attached) that providers must use if they disagree with a denial from any Excellus Blue Cross product that was denied due to clinical edits (bundling/CCI edits, authorization, medical necessity, etc.). Requests must be sent with the appropriate documentation to Excellus within 120 days from the date of denial in order to have the denied portion of the claim reconsidered. Attached is the section from the provider manual that outlines the protocol for disputing non-payment due to clinical editing (section 7-11 from the manual, attached):
"Providers who disagree with a clinical editing determination for a procedure code combination may request a clinical editing review. The Clinical Editing Review Request Form is available on the website or from Customer Care. To access the form, visit ExcellusBCBS.com/wps/portal/xl/prv/contactus/printforms/. Submit the form to the address listed on the form. In addition, disputes can be submitted online at ExcellusBCBS.com/ProviderCodingBilling (website login is required). It is important to include any clinical documentation that will support the request. Excellus BlueCross BlueShield will make a determination on the review and notify the provider in writing within 45 days of receipt of all necessary information. Unless otherwise stated in the provider’s participation agreement, Excellus BlueCross BlueShield allows 120 days from the date that the provider received the original claim determination to request a review. Excellus BlueCross BlueShield’s policy is to begin this 120-day time frame for review within five business days after the claim determination was sent to the provider.”
See links below for attachment:
Excellusbcbsprovidermanual 16updatecombofinalweb
Exclinicaleditingreviewrequestdec2015fillable